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DISEASES 



INFANCY AND CHILDHOOD. 



bunt*- 



A TREATISE 



DISEASES 



INFANCY AND CHILDHOOD. 

SECOND EDITION, 

ENLARGED AND THOROUGHLY REVISED. 



BY 

J. LEWIS SMITH, M.D., 

CCRATOR TO THE NURSERY AND CHILD'S HOSPITAL, NEW YORK; PHYSICIAN' TO THE INFANTS' 

HOSPITAL, WARD'S ISLAND J CONSULTING PHYSICIAN IN THE CLASS OF CHILDREN'S 

DISEASES, OUT-DOOR DEPARTMENT OF BELLEVUE HOSPITAL J CLINICAL 

LECTCRER ON DISEASES OF CHILDREN, AND PROFESSOR IN 

BELLEVUE HOSPITAL MEDICAL COLLEGE, 

NEW YORK. 




PHILADELPHIA: 

HENET C. LEA. 
1872. 



> AW 



Entered according to Act of Congress, in the year 1872, by 

HENRY C. LEA, 

In the Office of the Librarian of Congress, at Washington. All rights reserved. 



PHILADELPHIA: 
COLLINS, PRINTER. 



PREFACE TO THE SECOND EDITION 



The purpose of the author has beeu to present a description of 
the diseases of infancy and childhood succinctly, but at the same 
time in a sufficiently comprehensive manner to meet the require- 
ments of the medical student and practitioner. He has endeavored 
to incorporate in the treatise all recently ascertained facts relating 
to this branch of medical practice, and especially has it been his 
endeavor to recommend such modes of treatment as comport with 
and are suggested by our present knowledge of the pathology of 
early life, the efficacy of hygienic measures in the treatment of 
the young, and the recuperative powers of the system at this age. 

While the author has respected the opinions of previous 
writers, and has adopted them, so far as they appeared to be 
correct, he has depended much more for the material of his 
treatise on clinical observations and the inspection of the 
cadaver. Xecessarily, as a result of independent investigations, 
opinions are now and then expressed different from those which 
are commonly accepted. Xovel views have not, however, been 
presented, unless the author was fully satisfied that they were 
substantiated by a sufficient number of observations. 

In presenting to the profession the second edition of his work,, 
the author gratefully acknowledges the favorable reception ac- 
corded to the first. He has endeavored to merit a continuance 
of this approbation by rendering the volume much more com- 
plete than before. • Nearly twenty additional diseases have been 



VI PEEFACE TO THE SECOND EDITION. 

treated of, among which may be named Diseases Incidental to 
Birth, Rachitis, Tuberculosis, Scrofula, Intermittent, Remittent, 
and Typhoid Fevers, Chorea, and the various forms of Paralysis. 
Many new formulae, which experience has shown to be useful, 
have been introduced, portions of the text of a less practical 
nature have been condensed, and other portions, especially those 
relating to pathological histology, have been rewritten to correspond 
with recent discoveries. Every effort has been made, however, to 
avoid an undue enlargement of the volume, but, notwithstanding 
this, and an increase in the size of the page, the number of pages 
has been enlarged by more than one hundred. 

227 West 49th Street, New York, 
April, 1872. 



CONTENTS 



PART I. 

CHAPTER I. 

PAGE 

Infancy and Childhood 17 

CHAPTER II. 

Care of the Mother in Pregnancy 20 

CHAPTER III. 

Mortality of early Life — its Causes and Pretention . . .23 

CHAPTER IV. 
Lactation . . . 28 

Hindrances to Lactation, and physical conditions rendering it Im- 
proper — Facts and Rules in reference to Lactation — Human Milk — 
Modifications of the Milk in consequence of the Diet — Modification 
of Milk from its retention in the Breast — Modification of Milk from Age 
and Nervous Impressions — Modification of Milk by the Ca'tamenial 
Function and Pregnancy — Quantity of Breast Milk required by the 
Infant — Differences in Suckling Women as regards Quantity and 
Quality of Milk — Scantiness of Milk ; its Causes and Treatment. 

CHAPTER V. 

Selection of a \Yet-Nurse ' .49 

CHAPTER VI. 
Course of Lactation — Weaning 54 

CHAPTER VII. 

Artificial Feeding 57 

Composition of milk. 

CHAPTER VIII. 
Baths — Clothing GO 



Vlll CONTENTS. 



CHAPTER IX. 

PAGE 

Accidents and Ailments incidental to the Birth op the Infant, and 

Detachment of the Cord 62 

Apncea (Asphyxia) Neonatorum — Causes — Treatment — Caput Succe- 
daneum — Cephalsematoma. 

CHAPTER X. 

Conjunctivitis of the New Born 65 

Causes — Symptoms — Treatment. 

CHAPTER XI. 

Diseases of the Umbilicus 69 

Inflammation of the Umbilical Vein and Arteries — Treatment — Inflam- 
mation and Ulceration of Umbilicus — Treatment — Umbilical Granula- 
tions or Fungus — Treatment. 

CHAPTER XII. 

Umbilical Hemorrhage 72 

Sex, Age — Causes — Symptoms — Prognosis — Treatment. 

CHAPTER XIII. 

Diagnosis of Infantile Diseases 76 

General Observations — Features, External Appearance of Head, Trunk, 
and Limbs in Disease — Attitude — Movements — The Voice — Respiratory 
System — Respiration in Health — Respiration in Disease — Circulatory 
System — Pulse in Health — Pulse in Disease — Animal Heat — Digestive 
System — Nervous System, Pain. 



PAKT II. 

CONSTITUTIONAL DISEASES. 

SECTION" I. 
DIATHETIC DISEASES. 

CHAPT ER I. 

Rachitis 01 

Age — Anatomical Characters — Craniotabes — Symptoms — Complica- 
tions — Diagnosis — Prognosis — Treatment. 

CHAPTER II. 

Scrofula 104 

Causes — Anatomical Characters — Symptoms — Relation of Scrofula to 
Tuberculosis — Prognosis — Treatment : Prophylactic ; Curative. 



CONTENTS. IX 



CHAPTER III. 

PAGE 

Tuberculosis 122 

Etiology — General Anatomical Characters of Tuberculosis — Anatomi- 
cal Characters in Infancy and Childhood — Lungs — Abdominal Viscera 
— Stomach and Intestines — Symptoms — Bronchial Glands — Physical 
Signs — Lungs — Pleura — Stomach and Intestines — Prognosis — Treat- 
ment : Prophylactic ; Curative. 

CHAPTER IY. 

Syphilis 149 

Etiology — Clinical History — Manifestations — Coryza — Mucous Patches 
— Roseola — Pemphigus — Acne, Impetigo, and Ecthyma — Yisceral 
Lesions — Prognosis — Treatment. 



SECTION" II. 

ERUPTIVE FEVERS. 

CHAPTER I. 

Measles 159 

Symptoms — Complications : Capillary Bronchitis, True Croup, Pneu- 
monitis — Anatomical Characters — Nature — Diagnosis — Prognosis — 
Treatment. 

CHAPTER II. 

Scarlet Feyer 169 

Symptoms, Regular Form ; Irregular Form ; Malignant Form — Com- 
plications : Gangrene of Mouth, Articular Rheumatism, Serous Inflam- 
mation — Sequelae : Nephritis, Otorrhcea — A Case — Anatomical Char- 
acters — Nature — Diagnosis — Prognosis — Treatment — Prophylaxis. 

CHAPTER III. 

Variola— Varioloid .201 

Incubative Period — Stage of Invasion — Stage of Eruption — Stage of 
Desiccation — Desquamation — Varioloid — Mode of Death — Anatomical 
Characters — Complications — Prognosis — Diagnosis — Treatment. 

CHAPTER IY. 

Vaccinia . 212 

History of Vaccination — Appearances, Symptoms, Anomalies, Compli- 
cations, and Sequela? — Subsequent Vaccinations — Protection from 
Vaccination — Revaccination — Selection of Virus. 

CHAPTER V. 

Varicella 224 

Incubative Period — Symptoms — Diagnosis — Prognosis—Treatment. 



X CONTENTS. 

SECTION III. 
NON-ERUPTIVE CONTAGIOUS DISEASES. 

CHAPTER I. 

PAGE 

Diphtheria 227 

Anatomical Characters — Symptoms — Nature — Sequelae — Prognosis — 
Diagnosis — Treatment. 

CHAPTER II. 

Pertussis 247 

Symptoms — Complications — Convulsions — Bronchitis — Pneumonitis — 
Thrombosis — Diagnosis — Prognosis — Treatment. 

CHAPTER III. 

Parotiditis 261 

Nature — Diagnosis — Treatment. 

SECTION IV. 

OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever 263 

Symptoms — Prognosis — Treatment. 

CHAPTER II. 

Remittent Fever 267 

Symptoms — Diagnosis — Treatment. 

CHAPTER III. 

Typhoid Fever 269 

Causes — Anatomical Characters — Symptoms — Complications — Diagno- 
sis—Duration — Prognosis — Treatment. 

CHAPTER IY. 
Acute Rheumatism 277 

Causes — Symptoms — Duration — Prognosis — Diagnosis — Treatment, 

CHAPTER Y. 

Erysipelas 284 

Table of Cases — Age — Point of Commencement — Causes — Premonitory 
Symptoms — Symptoms — Prognosis — Duration — Modes of Death — 
Pathological Anatomy — Treatment. 



CONTEXTS. XI 

PAET III. 

LOCAL DISEASES. 
SECTION I. 

PAGE 

DISEASES OF THE CEREBROSPINAL SYSTEM . . 295 

CHAPTER I. 

Acephalds — Anencephalus . . . 298 

Anatomical Characters — Symptoms — Prognosis. 

CHAPTER II. 

Imperfect Brain 299 

A Case — Symptoms — Prognosis — Microcephalus— Atrophy of brain. 

CHAPTER III. 

Hypertrophy of Brain 302 

Pathological Anatomy — Causes — Cretinism — Symptoms — A Case — 
Diagnosis— Prognosis — Treatment. 

CHAPTER IV. 

Thrombosis in the Cranial Sinuses (Phlebitis) 308 

Anatomical Characters — Causes ; from Otitis — Symptoms — Diagnosis 
— Prognosis — Treatment. 
/ 

CHAPTER V. 

Congestion of Brain 314 

Active and Passive — Causes — Symptoms — Anatomical Characters- 
Prognosis — Treatment. 

CHAPTER YI. 

Intra-Cranial Hemorrhage (Meningeal Hemorrhage — Cerebral 
Hemorrhage) 319 

Causes — Anatomical Characters — Symptoms — Diagnosis — Prognosis — 
Treatment. 

CHAPTER VII. 

Congenital Hydrocephalus 330 

Anatomical Characters — Symptoms —Diagnosis— Prognosis — Treat- 
ment. 

CHAPTER VIII. 

Acquired Hydrocephalus 338 

Causes — Anatomical Characters — Location and Quantity of Fluid — 
Symptoms — Prognosis — Treatment. 



X CONTENTS. 

SECTION III. 
NON-ERUPTIVE CONTAGIOUS DISEASES. 

CHAPTER I. 

PAGE 

Diphtheria 227 

Anatomical Characters — Symptoms — Nature — Sequela? — Prognosis — 
Diagnosis — Treatment. 

CHAPTER II. 
Pertussis 247 

Symptoms — Complications — Convulsions — Bronchitis — Pneumonitis — 
Thrombosis — Diagnosis — Prognosis — Treatment. 

CHAPTER III. 

Parotiditis 261 

Nature — Diagnosis — Treatment. 

SECTION IV. 

OTHER GENERAL DISEASES. 

CHAPTER I. 

Intermittent Fever 263 

Symptoms — Prognosis — Treatment. 

CHAPTER II. 

Remittent Fever 267 

Symptoms — Diagnosis — Treatment. 

CHAPTER III. 

Typhoid Fever 269 

Causes — Anatomical Characters — Symptoms — Complications — Diagno- 
sis—Duration — Prognosis — Treatment. 

CHAPTER IV. 
Acute Rheumatism 277 

Causes — Symptoms — Duration — Prognosis — Diagnosis — Treatment. 

CHAPTER V. 

Erysipelas 284 

Table of Cases — Age — Point of Commencement — Causes — Premonitory 
Symptoms — Symptoms — Prognosis — Duration — Modes of Death — 
Pathological Anatomy — Treatment. 



CONTEXTS. XI 

PAET III. 

LOCAL DISEASES. 
SECTION" I. 

PAGE 

DISEASES OF THE CEREBRO-SPINAL SYSTEM . . 295 
CHAPTER I. 

ACEPHALCS — ANENCEPHALUS . . . 298 

Anatomical Characters — Symptoms — Prognosis. 

CHAPTER II. 

Imperfect Brain 299 

A Case — Symptoms — Prognosis — Mi crocephalus— Atrophy of brain. 

CHAPTER III. 

Hypertrophy of Brain 302 

Pathological Anatomy — Causes — Cretinism — Symptoms — A Case — 
Diagnosis — Prognosis — Treatment. 

CHAPTER IV. 

Thrombosis in the Cranial Sinuses (Phlebitis) 308 

Anatomical Characters — Causes ; from Otitis — Symptoms — Diagnosis 
— Prognosis — Treatment. 

CHAPTER V. 

Congestion of Brain 314 

Active and Passive — Causes — Symptoms — Anatomical Characters- 
Prognosis — Treatment. 

CHAPTER YI. 

Intra-Cranial Hemorrhage (Meningeal Hemorrhage — Cerebral 
Hemorrhage) 319 

Causes — Anatomical Characters — Symptoms — Diagnosis — Prognosis — 
Treatment. 

CHAPTER VII. 
Congenital Hydrocephalus 330 

Anatomical Characters — Symptoms — Diagnosis — Prognosis — Treat- 
ment. 

CHAPTER VIII. 

Acquired Hydrocephalus 338 

Causes— Anatomical Characters— Location and Quantity of Fluid — 
Symptoms — Prognosis — Treatment. 



Xll CONTENTS, 



CHAPTER IX. 

PAGE 

Meningitis, Simple and Tubercular 341 

Age — Anatomical Characters — Causes— Premonitory Stage — Symp- 
toms — A Case — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Spurious Hydrocephalus 363 

Anatomical Characters — Symptoms — Cases — Diagnosis — Prognosis — 
Treatment. 

CHAPTER XI. 

Eclampsia 369 

Essential, Symptomatic, Sympathetic, General, and Partial — Causes — 
Premonitory Stage — Symptoms — Anatomical Characters — Diagnosis 
— Prognosis — Treatment. 

CHAPTER XII. 

Tetanus Infantum ... . . 382 

Table of Cases— Period of Commencement— Frequency in Certain 
Localities — Causes — Symptoms — Prognosis — Mode of Death — Duration 
in Fatal Cases — Duration in Favorable Cases — Diagnosis — Preventive 
Treatment — Treatment. 

CHAPTER XIII. 

Internal Convulsions 405 

Different Forms — Causes — Anatomical Characters — Symptoms — Case 
— Diagnosis — Prognosis — Modes of Death — Treatment. 

CHAPTER XI Y. 

Chorea 415 

Age — Causes — Sex — Uterine Irritation — Anaemia — Rheumatism — 
Fright — Imitation — Intestinal Irritation — Lesions of Brain and Spinal 
Cord — Anatomical Characters — Symptoms — Prognosis — Course — 
Diagnosis — Treatment : Regimenal ; Medicinal. 

CHAPTER XY. 

Infantile Paralysis . 431 

Symptoms — Progress — Etiology— Anatomical Characters— Diagnosis 
— Prognosis — Treatment. 

CHAPTER XYI. 

Facial Paralysis 440 

Causes— Symptoms— Prognosis— Treatment. Paralysis with Apparent 
Hypertrophy : Symptoms— Anatomical Characters— Causes— Progno- 
sis — Treatment. 



CONTENTS. Xlll 

SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 
CHAPTER I. 

PAGE 
CORYZA 445 

Causes — Anatomical Characters — Symptoms — Prognosis — Treatment. 

CHAPTER II. 

Simple Laryngitis 449 

Symptoms — Chronic Form — Anatomical Characters — Treatment. 
Spasmodic Laryngitis : Causes — Symptoms — Anatomical Characters — 
Pathology — Diagnosis — Prognosis — Treatment. 

CHAPTER III. 

Pseudo-Membranous Laryngitis 458 

Causes — Anatomical Characters — Symptoms — Pathology — Diagnosis — 
Prognosis — Treatment — Tracheotomy. 

CHAPTER IY. 

Bronchitis 477 

Causes — Anatomical Characters — Symptoms — Capillary Bronchitis — 
Diagnosis — Prognosis — Treatment. 

CHAPTER Y. 

Pneumonitis 490 

Catarrhal, Croupous, and Interstitial — Causes — Hypostasis — Anatomi- 
cal Characters — Cheesy Pneumonitis — Symptoms — Physical Signs — 
Diagnosis — Prognosis — Treatment. 

CHAPTER YI. 
Pleuritis 507 

Causes — Cases — Anatomical Characters — E oipyema — Symptoms — 
Physical Signs — Case — Diagnosis — Prognosis — Treatment — Thoracen- 
tesis. 

SECTION III. 

DISEASES OF THE DIGESTIVE APPARATUS. 

CHAPTER I. 

Simple Stomatitis ; Ulcerous Stomatitis ; Follicular Stomatitis . 525 
Simple or Erythematic Stomatitis : Causes — Symptoms — Appearances 
— Treatment. Ulcerous Stomatitis : Anatomical Characters — Causes 
— Symptoms — Diagnosis — Prognosis — Treatment. Follicular Stoma- 
titis : Anatomical Characters — Causes — Symptoms — Diagnosis — Prog- 
nosis — Treatment. 



XIV CONTENTS. 



CHAPTER II. 

PAGE 

Thrush 533 

Anatomical Characters — Description of the Oidimn Albicans — Symp- 
toms — Causes — Diagnosis — Prognosis — Treatment. 

CHAPTER III. 

Gangrene of the Motjth 538 

Anatomical Characters — Age — Causes — Symptoms — Diagnosis — Prog- 
nosis — Treatment. 

CHAPTER IV. 
Dentition . . . . . 546 

Pathological Results of Dentition — Diagnosis — Treatment — Scarifica- 
tion of the Gums — Second Dentition. 

CHAPTER Y. 

Simple Pharyngitis ; Peri-Pharyngeal Abscess ; Oesophagitis . . 555 
Pharyngitis : Anatomical Characters — Causes — Symptoms — Prognosis 
— Diagnosis — Treatment. Peri-Pharyngeal Abscess : Age — Cause — 
Anatomical Characters — Symptoms — Duration — Diagnosis — Prognosis 
— Treatment. Oesophagitis : Anatomical Characters — Treatment. 

CHAPTER VI. 

Indigestion ; Congestion op Stomach ; Gastritis ; Follicular Gas- 
tritis ; Diphtheritic Gastritis ; Post-Mortem Digestion ; Soft- 
ening 567 

Indigestion : Causes — Symptoms — Prognosis — Treatment. Conges- 
tion of the Stomach. Gastritis : Causes — Age — Symptoms — Anatomi- 
cal Characters — Diagnosis — Prognosis — Treatment. Follicular Gas- 
tritis ; Diphtheritic Gastritis ; Post-Mortem Digestion ; Gelatinous 
Softening ; White Softening. 

CHAPTER VII. 

DlARRHCEA 585 

Non-Inflammatory Diarrhoea : Causes — Symptoms — Anatomical Char- 
acters — Diagnosis — Prognosis — Treatment. 

CHAPTER VIII. 

Intestinal Inflammation of Infancy 593 

Causes — Age — Symptoms — Microscopic Character of the Stools — Pulse 
— Anatomical Characters — Condition of the Liver — State of the Brain 
— Diagnosis — Prognosis — Treatment, Regimenal Measures, Medicinal 
Treatment ; Enemata, External Treatment. 

CHAPTER IX. 

Enteritis and Colitis in Childhood 620 

Causes— Symptoms— Diagnosis— Prognosis— Treatment. 



CONTESTS. XV 



CHAPTER X. 

PAGE 

Cholera Infantum 624 

Definition of the Term — Causes — Its Prevalence in the Cities — Symp- 
toms — Anatomical Characters — Diagnosis — Prognosis — Treatment. 

CHAPTER XI. 

Intestinal Worms 633 

Five Kinds — Description of them — Causes — Symptoms of Lumbrici — 
Diagnosis — Prognosis — Treatment — Use of Santonin, Spigelia, Cheno- 
podium. 

CHAPTER XII. 

Gastro-Intestinal Hemorrhage 646 

Three Varieties — Causes — Prognosis — Treatment. 



CHAPTER XIII. 

Intussusception 652 

Intussusception without Symptoms — Intussusception with Symptoms 
— Previous Health — Causes — Age — Seat and Pathological Anatomy — 
Intussusception in the Small Intestines — Cases — Intussusception in the 
Large Intestines — Symptoms — Diagnosis — Duration — Prognosis — 
Mode of Death — Treatment. 



SECTION IY. 

DISEASES OF THE CIRCULATORY SYSTEM. 

CHAPTER I. 

Cyanosis 674 

Literature of Cyanosis — Sex — Causes of the Malformation — Symptoms 
— Prognosis — Mode of Death — Modes of Compensation — Morbid 
Anatomy — Theories Relating to the Etiology of Cyanosis— Treatment. 

SECTION Y. 

SKIN DISEASES. 

CHAPTER I. 

Erythematous Diseases 695 

Erythema : Two Forms ; Idiopathic, Symptomatic — Prognosis — Diag- 
nosis — Treatment. Roseola : Symptoms — Causes — Prognosis — Diag- 
nosis — Treatment. Urticaria : Causes — Prognosis — Diagnosis — Treat- 
ment. 

CHAPTER II. 
Papular Diseases 702 

Lichen — Prurigo — Strophulus — Treatment. 



XVI CONTENTS. 



CHAPTER III. 

PAGE 

Eczema and Scabies 704 

Eczema; Simplex, Eubrum, and Impetiginodes — Symptoms — Diagno- 
sis — Treatment : General ; Local. Scabies : Diagnosis — Treatment. 



APPENDIX. 

A.— Dietary Formulae 714 

Falkland's Method of Preparing Milk for Infants — Lobb's Method — 
Meigs' Preparation — Liebig's Soup — Hassell's Comments — Raw Meat 
— Beef-tea — Liebig's Beef-tea — Hogarth's Essence of Meat — Routh's 
Comments. 

B. — Remarks on the Prevention op Scarlet Fever. By Wm. Budd, 
M.D 720 

C. — Remarks on the Diphtheritic Membrane. By Dr. Edward Rind- 
fleisch 725 

E. — Observations on the State op the Liver in Infantile Entero- 
colitis 726 

F. — Cases op Intussusception 728 

In the Small Intestines — Intussusception of Ileum into Colon — Invagi- 
nation of the Ccecum, Ileum and Ccecum, or Ileum, Ccecum, and Colon 
— Uncertain. 



DISEASES OF CHILDREN. 



PART I 



CHAPTER I. 
INFANCY AND CHILDHOOD. 

Infancy and childhood are in certain respects the most important 
and interesting periods of life. To the physiologist they are espe- 
cially interesting, because they are the periods of development and 
of greatest functional activity ; to the pathologist, because in them 
many diseases occur which are rarely or never observed in the 
other periods, or which present in these periods peculiar features ; 
to the physician and vital statistician, because in them there is the 
greatest amount of sickness, and largest number of deaths. 

Infancy extends from birth to the age of two and a half years, 
or till the completion of first dentition. In infancy the organs are 
delicately organized, containing a large proportion of water, and 
hence are easily injured. In this period the brain is rapidly de- 
veloped — more so than any other organ ; animal matter predomi- 
nates in the bones; the arteries are relatively large, the muscles 
small; the superficial veins are small. Fat is absent from the 
interior of the body, but abundant, in well-nourished infants, 
underneath the integument. The skin is delicate, and its temper- 
ature not much below that of the blood. At birth it has a red- 
dish hue, and is covered with soft fine hairs (lanugo). The reddish 
hue gradually fades into the healthy tint of infancy, and the hairs 
fall out. In the first two months the sweat glands have little 
functional activity, sensible perspiration being quite rare. Subse- 
quently perspiration is freer, and in certain diseased states is 
abundant (rachitis, etc.). The sebaceous glands in the first half 
of infancy are active, particularly upon the scalp, producing often 
2 



18 INFANCY AND CHILDHOOD. 

a pale yellow incrustation, consisting of sebaceous matter and epi- 
dermic cells. 

The secretions from the mucous surfaces commence at an early 
period. At birth the surface of the digestive tube is covered with 
more or less mucus, often in considerable quantity. The meconium 
is not considered, as formerly, to be a product of intestinal secre- 
tion. It consists of flat epithelial cells, fine hairs, oil globules, 
crystals of cholesterine, and brownish or yellowish masses of color- 
ing matter, probably from the liver. It is supposed that, with the 
exception of the 1 coloring matter, the meconium is derived mainly 
from the amniotic fluid which the foetus has swallowed. 

The most wonderful change occurring in the system at birth, 
through the exigencies of the new life, is that in the circulation. 
The flow of blood being interrupted, thrombi form in the umbilical 
vein, and arteries, and in the ductus arteriosus, and ductus venosus, 
and these vessels gradually atrophy, becoming finally shrivelled 
but permanent cords. I have many times at autopsies removed 
the plug from the ductus arteriosus when death had occurred as 
late as the third week. The foramen ovale closes slowly. I have 
ordinarily found it open till near the end of the first half year, but 
the valve closes fully the aperture, so that there is no detriment to 
the circulation. Both the pulse and respiration are more frequent 
during infancy than childhood, and are more readily accelerated by 
moral and physical causes. 

The stomach is less elongated, and emesis more readily produced 
than in the adult. The liver is large, occupying at birth nearly 
half of the abdominal cavity, but growing smaller in successive 
months. The appetite is good and digestion active, so that hunger 
when appeased, soon returns. The thymus gland, at birth about 
the size of an unexpanded lung, slowly atrophies, but it does not 
totally disappear till after infancy. 

The kidneys, distinctly lobulated at birth, gradually change their 
form, so as to present in the last part of infancy nearly the shape 
of the organ in the adult. The renal secretion commences early, 
even before birth. The kidneys seldom undergo degenerative 
changes as in the adult, but they are liable to congestions and in- 
flammations. During the first month, and esjDecially the first fort- 
night, crystals of uric acid, and the urates, are often found in the 
urine, in a state of apparent health, causing more or less fretfulness 
in their elimination, staining the diaper, and not infrequently 
being arrested in the tubules of the pyramids, where they can be 
seen as pink-colored spots or lines (uric acid infarction). These 



CHILDHOOD. 19 

deposits of uric acid and the urates may even occur in the foetus, 
producing obstruction and inflammation of the renal tubes. Con- 
genital cystic degeneration of the kidneys is, in the opinion of 
Virchow, due to them. In early infancy the senses are imperfectly 
developed, the eyes being attracted only by bright objects, and the 
sense of hearing affected only by loud noises. Sleep is the normal 
state in the first weeks of life ; as the age of the infant advances, 
less and less sleep is required ; but the oldest infants need more than 
children, and several hours more than adults. 

The new-born infant is apparently destitute of mental faculties. 
It seeks the breast by instinct, and it exhibits no perception or 
reflection. The loud cries with which it commences its existence 
are not from anger or suffering ; they appear to be normal, like the 
act of nursing, and providentially designed in order to expand the 
lungs. It is not till the close, or near the close, of the first month, 
that the gray substance of the brain begins to appear — the probable 
seat of the mind, and the source of all mental phenomena. Per- 
ception and curiosity are early manifested. The infant, as Edmund 
Burke has remarked, is constantly seeking new objects for its 
amusement, rejecting old playthings for such as possess more 
novelty. Reflection, a higher faculty of the mind, appears at a 
later period. The mind and the bodily organs in infancy are, in a 
high degree, impressionable. Anger is excited by trivial causes, 
but is easily appeased ; and the various functions in the system are 
disturbed by agencies which in youth or manhood would have no 
appreciable effect. 

Childhood extends from infancy to the age of fifteen years or 
puberty. It is a period of great physical activity, and of rapid 
growth. The functions of the various organs are performed with 
more moderation than in infancy, and are less frequently deranged. 
The volume of the brain continues to increase rapidly, and it be- 
comes firmer than in infancy. It is estimated that by the seventh 
year the weight of this organ has doubled. The mind now exerts 
a controlling influence over the actions of the individual. The 
digestive organs have changed, so that solid food is required. 
Most of the glandular organs are less active than in the greater 
part of infancy, and some of them, as the liver, are relatively smaller. 
The pulse and respiration gradually become less frequent as the 
child advances in age. 



20 CAEE OF THE MOTHER IN PREGNANCY. 



CHAPTER II. 

CARE OF THE MOTHER IN PREGNANCY. 

The frequency of miscarriages and still-births, and the large 
number of ill-formed and puny infants, born to a precarious and 
short existence, render imperative, on the part of the mother, a 
strict observance of the laws of health, and an avoidance of all 
exciting or perturbating influences during the time when the foetus 
is being developed. The diet should be plain and easily digested, 
but nutritious. There is often a craving in pregnancy for unusual 
articles of food. These may sometimes be allowed within certain 
limits, provided they are such as do not derange the stomach. 
Meats and animal broths, together with vegetables and farinaceous 
food, should constitute the ordinary diet, and should be taken at 
regular intervals. 

Daily exercise, never violent, but moderate and gentle, is re- 
quisite. "No exercise is better, none safer and more likely to con- 
tribute to cheerfulness and healthy functional activity of the 
organs, than the ordinary household duties. Lifting heavy weights, 
or work which, like washing and ironing, causes great and con- 
tinued action of the abdominal muscles, should be avoided. Such 
exercise is highly injurious, and is apt to produce premature labor. 
Exercise in the open air, on foot or by an easy conveyance, con- 
duces to the health of the mother, and the growth and develop- 
ment of the foetus. On the other hand, rapid riding over rough 
roads is one of the most dangerous modes of exercise. It has been 
known to destroy the foetus, which up to that time had been appa- 
rently vigorous. When such a result occurs, there is probably 
more or less detachment of the placenta. 

It being a matter of the utmost importance that the health of 
the mother should continue good during gestation, any disease 
which she may have in this period, and which affects her nutrition 
or the character of her blood, should be promptly cured if practi- 
cable, and with the least possible reduction of the vital powers. 
Intermittent fever, occurring during gestation, should never be 
allowed to continue. It seriously retards foetal development, and 



MATERNAL IMPRESSIONS. 21 

may produce miscarriage. Unless it is controlled by proper 
measures, the offspring, though born at term, is puny and emaci- 
ated. Syphilis, in the pregnant woman, also requires treatment. 
This disease, readily transmitted from the mother to the foetus 
through the ovum or the uterine circulation, may be eradicated by 
anti-syphilitic treatment of the mother, or at least so modified that 
the infant is born vigorous and healthy. 

The pregnant woman should avoid all causes of undue mental 
excitement. This is almost as necessary as the avoidance of great 
physical exertion. There is, during pregnancy, unusual suscep- 
tibility to mental impressions, and this should be borne in mind 
not only by the woman herself, but by those who associate with 
her. 

Strong emotions, whether of joy, sorrow, or anger, affect pri- 
marily the nervous system, but indirectly most of the organs of 
the body. Observations have long established the fact, that such 
emotions influence the state and functions not only of the digestive 
and glandular, but muscular organs, as the heart and uterus. 
Physicians are familiar with cases in which vivid mental impres- 
sions produced uterine contractions, and even miscarriage, or have 
disturbed the catamenial function. Therefore, the associations and 
cares of pregnant women should be such as conduce to cheerfulness 
and equanimity. 

It is the popular belief, and the belief of many physicians, that 
vivid mental impressions sometimes have a direct effect on the de- 
velopment of the foetus. Many eases are on record in which infants 
were born with marks or deformities, corresponding in character 
with objects which had been seen and had made a strong impres- 
sion on the maternal mind at some period of gestation. "Whether 
the mind of the mother exerts a controlling influence on the form 
and color of the foetus, is a subject of great interest to the psycho- 
logist as well as physiologist and physician, since it involves no 
less a question than the power and scope of the human mind. 
Violent emotions, it is admitted, may affect directly most of the 
important organs in the system. They may derange the liver, 
causing jaundice, accelerate, or for a moment suspend the heart's 
action, stimulate the kidneys, causing diuresis, or even the intes- 
tinal follicles, causing watery evacuations. But with all these 
organs the brain is connected by nerves which anatomy reveals. 
On the other hand, the mother and foetus have a distinct existence 
as regards their nervous systems, and even their blood. Still, the 
multitude of facts which have accumulated justify the belief that,. 



22 CARE OF THE MOTHER IN PREGNANCY. 

deformity or other abnormal development of the foetus is, some- 
times, due to the emotions of the mother. Some of the cases 
related by Dr. Whitehead, in his work on hereditary diseases, are 
very striking and difficult to explain, on the ground of coincidence. 
I have met the following cases. An Irish woman of strong 
emotions and superstitions was passing along a street in the first 
months of her gestation, when she was accosted by a beggar, who 
raised her hand, destitute of thumb and fingers, and in " God's 
name" asked for alms. The woman passed on : but reflecting in 
whose name money was asked, felt that she had committed a great 
sin in refusing assistance. She returned to the place where she had 
met the beggar, and on different days, but never afterwards saw 
her. Harassed by the thought of her imaginary sin, so that for 
weeks, according to her statement, she was made wretched by it, 
she approached her confinement. A female infant was born, other- 
wise perfect, but lacking the fingers and thumb of one hand. The 
deformed limb was on the same side, and it seemed to the mother 
to resemble precisely that of the beggar. In another case which I 
met, a very similar malformation was attributed by the mother of 
the child to an accident occurring to a near relative, which necessi- 
tated amputation during the time of her gestation. I examined 
both of these children with defective limbs, and have no doubt of 
the truthfulness of the parents. In May, 1868, 1 removed a super- 
numerary thumb from an infant, whose mother, a baker's wife, 
gave me the following history: No one of the family, and no an- 
cestor, to her knowledge, presented this deformity. In the early 
months of her gestation she sold bread from the counter, and 
nearly every day a child with double thumb came in for a penny 
roll, presenting the penny between the thumb and the finger. 
After the third month she left the bakery, but the malformation 
was so impressed upon her mind, that she was not surprised to see 
it reproduced in her infant. 

Professor William A. Hammond, of this city, in an interesting 
paper on the "Influence of the Maternal Mind," etc. {Quarterly 
Journal of Psychological Medicine, January, 1868), says : " The chances 
of these instances, and others, which I have mentioned, being due 
to coincidence, are infinitesimally small, and though I am careful 
not to reason upon the principle of post hoc, ergo propter hoc, I 
cannot, nor do I think any other person can, no matter how logical 
may be his mind, reason fairly against the connection of cause and 
effect in such cases. The correctness of the facts can only be ques- 
tioned; if these be accepted, the probabilities are thousands of mil- 



MOETALITY OF EARLY LIFE. 23 

lions to one, that the relation between the phenomena is direct." 
Professor Dalton also says {Human Physiology), " there is now little 
room for doubt that various deformities and deficiencies of the 
foetus, conformably to the popular belief, do really originate in 
certain cases from nervous impressions, such as disgust, fear, or 
anger, experienced by the mother." The observations on which 
this belief is based relate both to man and the lower animals. A 
very strong argument in its support is, as Professor Hammond 
remarks, the popular opinion, which dates back to the time of 
Jacob (Genesis xxx.). An almost universal sentiment, running 
through centuries, is rarely wholly fallacious. It has some truth 
for its foundation, especially when, as in this instance, the subject 
is one of observation. 

If maternal emotions affect the development of the exterior of 
the foetus, as observations show, and physiologists admit, the pre- 
sumption is strong, that they may affect also the proper develop- 
ment, and adjustment of the parts of the brain, an organ so com- 
plex and delicate, and may therefore give rise to idiocy. Dr. Seguin 
{Idiocy and its Treatment, etc., New York, 1866) thus remarks on 
this point: "Impressions will, sometimes, reach the foetus, in its 
recess, cut off its legs or arms, or inflict large flesh wounds, before 
birth, . . . from which we surmise that idiocy holds unknown 
though certain relations to maternal impressions, as modifications 
to placental nutrition." 

In view of such important facts, the duty of the pregnant woman 
is rendered the more imperative to avoid the presence of disagree- 
able and unsightly objects, as well as all causes of excitement, and 
to remove, as soon as possible, vivid and unpleasant impressions, 
by quiet diversion of the mind. 



CHAPTER III. 

MOETALITY OF EAKLY LIFE— ITS CAUSES AND PREVENTION. 

No fact is better known in the profession, than that the first 
years of life constitute the period of greatest mortality. 

In England, where there is an accurate registration of births and 
deaths, statistics show fifteen deaths in every hundred infants in 
the first year of life, and between four and five deaths in the first 



24 MORTALITY OF EARLY LIFE. 

month. Statistics on the continent correspond with those in Eng- 
land, as regards the periods of greatest mortality. Quetelet says, 
"... there die during the first month after birth, four times 
as many children as during the second month after birth, and 
almost as many as during the entirety of the two years that follow 
the first year, although even then the mortality is high. The 
tables of mortality prove, in fact, that one-tenth of children born, 
die before the first month has been completed." 

In this country, in consequence of deficient registration of births, 
the percentage of deaths to births cannot »be accurately ascertained. 
In this city, 53 per cent, of the total number of deaths occur under 
the age of fLye years, and 26 per cent, under the age of one year. 
According to the census of 1865, there were in New York city 
95,020 children under the age of five years, and during the ftv& 
years ending with 1865, 49,000 children five years old and under 
had died. Therefore, according to these statistics, more than one- 
third of all the infants born in this city die under the age of -Q.YQ 
years. An error, however, occurs from the fact that, while the 
death statistics were complete, it is known there were more children 
in the city than were embraced in the census returns. Still it may, 
I think, be safely stated that one-fourth of the children born in 
this city die before the age of five years. 

In less crowded cities and the rural districts, it is known that 
the percentage of deaths in the first years of life to the total num- 
ber of deaths is considerably less than in New York city, but it is 
nevertheless large. 

As the child advances towards puberty, the liability to sickness 
and death gradually diminishes, but even the last years of child- 
hood present a considerably larger percentage of deaths to the 
population than does youth or manhood. 

The causes of this great mortality of infants and children, and 
the means of diminishing it, deserve careful consideration. 

Some of the causes which conspire to produce this mortality are 
in a measure unavoidable. Such are congenital vices of formation 
of internal organs. Many of the internal malformations neces- 
sarily occasion an early death. Cases of anencephalus, most cases 
of congenital hydrocephalus, of spina bifida, of cyanosis, are fatal 
before the close of infancy. These defects of formation we cannot 
detect before birth, and their causes are often obscure. Some of 
them seem to result from inflammation, believed to be, occasionally, 
syphilitic, developed at some period of foetal existence. Other in- 
ternal malformations are attributable to perturbating influences, 



CAUSES OF INFANTILE MORTALITY. 25 

operating temporarily on the mother during gestation. But in a 
large proportion of cases, we cannot assign the cause. Obviously, 
only partial success can attend our efforts, as regards prevention 
in these cases, and almost no success, as regards the use of remedial 
measures. 

Another obvious cause of the great mortality of early life, is 
natural feebleness of system, especially in infancy. The younger 
the patient, prior to the middle period of life, the sooner are the 
vital powers exhausted by disease. Hence a larger proportion of 
infants succumb to the same malady than children, and a larger 
proportion of children than adults. This statement is true of in- 
fancy and childhood in general. It is a law in nature, and cannot 
be changed by art. But there are many infants born with heredi- 
tary disease, or a strong predisposition to disease, through a fault, 
which is, in a degree, remediable, in the system of one or both 
parents, as, for example, the syphilitic, scrofulous, or tubercular 
diathesis. Parents seriously affected by such diseases cannot, with- 
out corrective treatment, have healthy offspring. Their children 
are among the first to droop and die, either directly from the 
inherited disease, or from feebleness of constitution, which such 
disease entails, and which renders them an easy prey to other dis- 
eases. The duty of the physician, as regards such parents, is obvi- 
ous. He may, by therapeutic and hygienic measures, secure a more 
healthy progeny, and, so far as he can do this, he aids in diminish- 
ing the infantile mortality. He may sometimes, by timely mea- 
sures directed to the infant, establish a better state of health. 

The subject of hereditary disease is one of great interest and 
importance, especially as regards the city population. Inherited 
affections are less common in the country, but in the city they con- 
tribute largely to the number of deaths in early life. 

Another important cause of the great mortality of infants and 
children, is the fact that they are peculiarly liable to certain severe 
and fatal diseases. The zymotic diseases, which, as a rule, occur 
but once, are more common at this age than subsequently. Some 
of these, as scarlet fever, greatly increase the number of deaths. 
The zymotic diseases are for the most part infectious. Hence they 
are very prevalent and fatal in cities, where there is much greater 
intercourse of children than in the country. Scarlet fever is one 
of the six most fatal diseases in E"ew York city. The prevention 
of contagious diseases obviously depends, in great measure, on 
isolation, which it is the duty of the physician to advise. Boards 
of health, or civil authorities, may also do something as regards 



26 MORTALITY OF EARLY LIFE. 

the schools, to prevent the spread of these diseases. One of them, 
the most loathsome and dreaded of all, namely, smallpox, the phy- 
sician has the power to prevent. Some of the most fatal diseases 
of life, not contagious, as croup and capillary bronchitis, also occur 
in infancy and childhood, materially increasing the mortality. 
These local affections cannot be prevented by the physician, but 
only by judicious hygienic management on the part of families. 

Another obvious and important cause of the mortality of early 
life, is the anti-hygienic condition or state in which many children 
live in consequence of the poverty or gross negligence of parents. 

Residence in insalubrious localities, personal and domiciliary 
uncleanliness, exposure without proper protection to vicissitudes of 
weather, are fertile causes of sickness and death. Hence one reason 
of the great infantile mortality among the city poor, who live in 
damp and dark alleys, and in crowded and filthy tenement-houses, 
breathing night and day an atmosphere loaded with noxious gases. 
All physicians are aware how the malignant diseases, such as 
Asiatic cholera, cholera infantum, diphtheria, and typhus fever, 
seek the quarters of the city poor, and what terrible havoc they 
make there. All are aware, also, what wonderful recoveries occur 
when feeble and attenuated infants, gradually sinking with chronic 
disease, induced in great measure by this malaria, are transferred 
from such localities to the pure air of the country. 

Careless management of young children, as regards dress, in- 
creases greatly the liability to local diseases, such as commonly 
occur from exposure to cold. These are inflammatory affections, 
seated chiefly upon the mucous surfaces, but sometimes in paren- 
chymatous organs. Adults, aware of the effect of sudden change 
of temperature from warm to cold, or of exposure to currents of 
air, protect themselves by additional clothing. Such precautionary 
measures are often lacking in the management of young children, 
and hence one cause of their great liability to local affections, both 
of the respiratory and digestive organs. 

Routh, in his excellent treatise on Infant Feeding, says : "Among 
the most pernicious influences to young children, however, we may 
include cold. The change of temperature from 45° to 4° or 5° 
below zero, as before stated, producing an increase of mortality in 
London alone of three to five hundred. As out of one hundred 
deaths, however, from all specified causes, nearly twenty-four 
occur to children under one, and thirty-six to children under five ; 
the great increase of mortality to children by cold, is thus, at 
once, made obvious. Indeed, it is a household word amongst us, 



IMPROPER FEEDING. 27 

winch takes its origin from the Registrar-General's returns, that a 
very cold week always increases the mortality of the very young 
and the very aged." 

Lastly, a very important cause of mortality in early life is the 
use of improper food. In infants, artificial feeding in place of 
the aliment which nature has provided for them, and, in children, 
the use of innutritious or indigestible articles of diet, give rise to 
diarrhceal maladies, emaciation, and death in numerous instances. 
Sometimes, also, defective alimentation is the cause of scrofulous 
or tuberculous ailments, and sometimes it gives rise to a cachexia 
or feebleness of system, which, without engendering any positive 
disease, renders those thus affected less able to support disease 
induced by other causes. A committee, of which Prof. Austin 
Flint, Jr., was chairman, appointed in 1867 to revise the "dietary 
table of the Children's Nurseries on Randall's Island," state, with 
much truth and force: "Children .... are not capable of resist- 
ing bad alimentation, either as regards quantity, quality, or variety. 
At that age the demands of the system for nourishment are in 
excess of the waste ; the extra quantity being required for growth 
and development. If the proper quantity and variety of food be 
not provided, full development cannot take place, and the children 
grow up, if they survive, into puny men and women, incapable of 
the ordinary amount of labor, and liable to diseases of various 
kinds. This is frequently illustrated in the higher walks of life, 
particularly in females ; for many suffer through life from improper 
diet in boarding-schools, due to false and artificial notions of deli- 
cacy or refinement. After a certain period of improper and de- 
ficient diet in children, the appetite becomes permanently impaired, 
and the system is rendered incapable of appropriating the amount 
of matter necessary to proper development and growth." 

Improper feeding, like other causes of mortality, is much more 
injurious, much more frequently the cause of death, in the city than 
country. Statistics in Europe, as well as this side of the Atlantic, 
establish this fact. It is in infancy, and especially in the first year, 
that the use of unwholesome food entails the most serious conse- 
quences. ~No artificially prepared food is a good substitute for the 
mother's milk, and hence artificial feeding of the infant, unless 
under the most favorable circumstances, results disastrously. In 
the country, where salubrious air and sunlight conspire to invigo- 
rate the system, and a robust constitution is inherited, and where 
cow's milk fresh and of the best quality is readily obtained, lacta- 



28 LACTATION. 

tion is not so necessary for the well-being of the infant ; but in the 
city its importance cannot be too strongly urged. 

The foundlings of the cities afford the most striking and con- 
vincing proofs of the advantage of lactation. In some cities found- 
lings are wet-nursed, while in others they are dry-nursed, and the 
result is always greatly in favor of the former. Thus, on the 
continent, in Lyons and Parthenay, where foundlings are wet- 
nursed almost from the time that they are received, the deaths are 
33.7 and 35 per cent. On the other hand, in Paris, Rheims, and 
Aix, where the foundlings are wholly dry-nursed, their deaths are 
50.3, 63.9, and 80 per cent. 

In this city the foundlings, amounting to several hundred a year, 
were, till recently, dry-nursed ; and, incredible as it may appear, 
their mortality, with this mode of alimentation, nearly reached 
100 per cent. Recently wet-nurses have been employed, for a part 
of the foundlings, with a much more favorable result. 

These facts, to which others might be added from the experience 
of European cities, show the importance of lactation as a means 
of reducing infantile mortality in the cities. "What has been stated 
as regards the result of artificial feeding of foundlings, is true, in 
great measure, in reference to all city infants. The ill effect of 
artificial feeding is well known in this city, and it is the common 
practice in families to employ a hired wet-nurse, if, for any reason, 
the mother's milk is insufficient. 

When the infant has reached the age at which it is proper to 
wean it, the digestive organs are less frequently deranged by errors 
of diet. More substantial food, and considerable variety in it, may 
now be not only safely allowed, but are required by the wants of 
the system. Still, the feeding of children in health, and much 
more in sickness, is a subject of great importance. Therefore lac- 
tation, and the diet of infancy and childhood, will occupy our 
attention in the following pages. 



CHAPTER IV. 

LACTATION. 

It is desirable that the infant, as soon as it requires nutriment, 
should receive breast milk. If it is fed, for a few days, with the 
bottle or spoon, it may be difficult finally to induce it to take the 



HINDRANCES TO LACTATION. 29 

breast ; therefore it is well to determine early whether the mother 
will be able to wet-nurse her infant, so that, if unable, suitable 
provision may be made. 

The matter of determining, beforehand, the capability of the 
mother for wet-nursing has been investigated by Dr. Donne*, of 
Paris, and in his treatise on Mothers and Infants he describes the 
mode in which it may be ascertained. The desired information, in 
his opinion, may be acquired by examining the colostrum, which 
is secreted in small quantity, in the last months of gestation, and 
which can be squeezed from the breast in sufficient quantity for 
inspection. 

In some women, according to Dr. Donne', the colostrum is so 
scanty that only a drop, or half a drop, can be obtained from the 
nipple by careful pressure. This will be found by the microscope 
to contain but few milk globules, ill-formed, and a few granular 
bodies, such as the colostrum ordinarily contains. Such women 
almost invariably furnish poor milk, and in small quantity. In 
other women the colostrum is abundant, but thin, resembling gum- 
water ; it lacks the yellow streaks and viscous character of ordinary 
colostrum, and it flows readily from the nipple. The milk of such 
women is sometimes scanty, sometimes abundant, but it is watery 
and deficient in nutritive principles. In a third class of women, 
the colostrum is pretty abundant, and it contains yellowish streaks, 
of more or less consistence, which are found to be rich in milk 
globules, of good size, and without the admixture of mucous glo- 
bules. "Women furnishing such colostrum in the last weeks of 
gestation will have sufficient milk, and of good quality. These 
latter women make the best wet-nurses. 



Hindrances to Lactation and Physical Conditions Rendering it Improper. 

The primipara often experiences difficulty in wet-nursing in con- 
sequence of a depressed state of the nipple. It is not sufficiently 
prominent to be readily grasped by the mouth, and after ineffectual 
attempts the infant becomes fretful when applied to the breast and, 
perhaps, for a time refuses it altogether. Multipara occasionally 
experience the same inconvenience, but it is not common when 
there has once been successful lactation. By calmness and perse- 
verance on the part of the mother, the infant can usually be made 
to seize the nipple in the course of a week. 

Depression of the nipple is, to a certain extent, the result of 
pressure upon it by the dress during gestation. The state of the 



30 LACTATION. 

nipples should, indeed, in those who have never suckled, receive 
early attention, even before the birth of the infant. Tightness of 
dress around the breast, as indeed upon every part of the body, 
should be avoided, and from time to time gentle traction should 
be made upon the nipple, if it is depressed. It may be drawn out 
by the fingers of the mother several times each day, or by a com- 
mon breast-pump, or by suction with a tobacco-pipe, the edge of 
the bowl having been smoothed. Occasionally, in these cases of 
deficient nipple, the mother, fatigued and discouraged by her fre- 
quent ineffectual attempts to induce the infant to nurse, becomes 
feverish and excited, so that the quantity of her milk is sensibly 
diminished. The physician should assure her, as he usually can 
with confidence, that in a few days, as the baby becomes a little 
stronger, there will be no difficulty in its nursing. Some women 
are unremitting in their endeavors to procure nursing. This should 
be forbidden, since the lack of sleep, and the nervousness which 
such constant attention produces, tend to defeat the object which 
they have in view, by diminishing the secretion of milk. The 
application of the infant to the breast once in an hour and a half 
to two hours is quite sufficient. In some cases, when practicable, 
the aid of another woman, whose infant is a little older, is in- 
valuable. The exchange of infants for a few times may remedy 
the difficulty. 

Occasionally lactation is rendered difficult and painful by too 
long delay before applying the infant to the breast. "When the 
mother has rested a few hours after her confinement, from three to 
six in ordinary cases, lactation may commence. There is, at first, 
but very little milk, often only a few drops, but the secretion is 
promoted by nursing, so that the requisite amount is sooner ob- 
tained than when the infant is kept from the breast till the second 
or third day. If, as some physicians advise, suckling is deferred 
till the breasts are full and tender, and if, as is often the case with 
primiparse, the nipples are also tender, many mothers lack the for- 
titude required to allow their infants to obtain a sufficient amount 
of milk. Excoriated and fissured nipples constitute a serious im- 
pediment to lactation. They are very sensitive on pressure, and 
are long in healing. They are fully described in works which 
relate to female diseases, and their treatment pointed out. Occa- 
sionally fissured nipples do harm to the infant by the blood which 
escapes and is swallowed with the milk. A case is related in 
which positive indigestion was caused in this way, the infant 
vomiting, after each nursing, milk mixed with blood. The local 



HINDRANCES TO LACTATION. 31 

hindrances to lactation described above can, in most instances, be 
relieved in the course of a few weeks. 

There is, occasionally, a constitutional state of the mother which 
necessitates either the employment of a hired wet-nurse or wean- 
ing. This is the case when there is a strong tendency to tubercu- 
losis. If the complexion is pallid, and the system at all emaciated, 
and suckling is attended by more or less exhaustion, and if with 
fair trial of wine and tonics there is no improvement, the physician 
is justified in forbidding farther attempts at wet-nursing. If there 
is, under such circumstances, an hereditary tendency to tubercu- 
losis, it is his duty to interdict it positively. The opinion of the 
physician, in such a matter, should be formed after mature delibe- 
ration. There are many women who, suffering temporarily from 
depression, and discouraged, are ready at once to abandon their 
infants to the care of others, with the least encouragement on the 
part of the physician to do so, but who, by attention to their own 
health, and especially by taking more sleep, soon recover from their 
depression and become good wet-nurses. On the other hand, night- 
sweats, a cough, and progressive decline in health, show the need 
of immediate suspension of wet-nursing. 

Sometimes women, prior to pregnancy, present indubitable evi- 
dence of tuberculosis, but by the improved general health which 
attends pregnancy, the disease is temporarily arrested. Such 
women should never suckle their infants. If they do, they soon 
lose all that was gained, and the disease advances rapidly. These 
objections to wet-nursing in such a state of health apply to the 
mother. There are also objections as regards the infant. The milk 
of those in decidedly infirm health, is deficient in nutritive prin- 
ciples. Their infants, therefore, are ill-nourished, and, if they 
have inherited a predisposition to tuberculosis, there is great danger 
that this disease will be developed in them ; whereas with healthy 
wet-nursing, even a strong predisposition may remain latent. M. 
Donne relates the following instructive cases, which show the 
danger which sometimes attends suckling, and the imperative ne- 
cessity which may arise of discontinuing it. "A very light-com- 
plexioned young mother, in very good health, and of a good con- 
stitution, though somewhat delicate, was nursing for the third 
time, and as regarded the child successfully. All at once this 
young woman experienced a feeling of exhaustion. Her skin be- 
came constantly hot; there were cough, oppression, night-sweats ; 
her strength visibly declined, and in less than a fortnight she pre- 
sented the ordinary symptoms of consumption. The nursing was 



32 LACTATION. 

immediately abandoned, and from the moment the secretion of 
milk had ceased, all the troubles disappeared." "A woman of 
forty years of age . . . having lost, one after another, several 
children, all of whom she had put out to nurse, determined to 
nurse the last one herself. . . . This woman, being vigorous 
and well-built, was eager for the work, and, filled with devotion 
and spirit, she gave herself up to the nursing of her child with a 
sort of fury. At nine months, she still nursed him from fifteen to 
twenty times a day. Having become extremely emaciated, she 
fell all at once into a state of weakness, from which nothing could 
raise her, and two days after the poor woman died of exhaustion." 1 

Constitutional syphilis in the mother does not contra-indicate 
lactation. It is probable that the infant also has it. The mother 
should take anti-syphilitic remedies, which will eradicate the dis- 
ease in herself, and also, if it be present, in the infant. Febrile 
affections, also, do not in general contra-indicate lactation. They 
may, however, for a time, diminish the quantity of milk, or impair 
its quality. If, however, the mother is in a critical state, or much 
reduced, whatever the disease, suckling should cease. "Whether 
or not the infant should be taken from the breast, if the mother is 
suffering from one of the essential fevers, depends on the degree 
of her exhaustion. Twice I have known newly-born infants nurse 
their mothers through attacks of scarlet fever, without contracting 
it, but suffering immediately afterwards from severe and protracted 
eczema. In the country, where artificially-fed infants as a rule 
do well, it might be best to wean if the mother is affected with 
such a disease, but in the city eczema is less dangerous than the 
diarrhceal affections, which early weaning is apt to entail. In most 
cases of typhus or typhoid, weaning or procuring a wet-nurse is 
necessary, on account of the depression of the vital powers which 
this disease produces. 

Inflammatory affections, unless of a dangerous character, do not 
ordinarily interfere with lactation, except that the quantity of 
milk may be somewhat diminished. In severe inflammation, it 
may be so necessary to husband the strength, or to keep the patient 
perfectly quiet, that suckling her infant would be injudicious. It 

1 A very similar case recently occurred in my practice. A young and healthy 
woman from the country, suckling her second infant, on coming to the city, lived 
in a dark and very imperfectly ventilated room, on the first floor, and in the rear of 
a crowded tenement-house. She soon lost her appetite, but continued suckling for 
three months, when she became so anaemic and feeble that she was compelled to 
seek medical advice. She died without local disease, notwithstanding the most 
nutritious diet and the free use of stimulants and tonics. 



FACTS AND RULES IN REFERENCE TO LACTATION. 33 

should then he transferred to a wet-nurse or weaned. Inflamma- 
tion of the hreast often presents an impediment to lactation. It is 
a common and painful affection, suspending, or greatly diminish- 
ing the secretion of milk in the affected gland. Nursing should 
cease as soon as there are evident signs of inflammation, unless it is 
limited to a small part of the gland. General heat of the hreast, 
tenderness and induration extending over a considerable part of it, 
are signs which indicate the immediate removal of the infant from 
it. Lactation must he restricted to the unaffected side. It is 
often the case that the volume of the inflamed gland is considerably 
increased from the afflux of blood to it, and from the interstitial 
exudation, while it contains little or no milk, and attempts at lac- 
tation, under such circumstances, are injurious to the mother as 
well as infant. The cause of the swelling should be explained to 
the mother, who commonly attributes it to the accumulation of 
milk, and worries herself and the infant, in attempting to make it 
nurse. As the inflammation abates, by resolution, or more com- 
monly by suppuration, and the normal secretion returns, the first 
milk, which is apt to be thick and stringy, should be rejected, after 
which the infant may nurse as usual. Occasionally, the abscess, 
which has formed in the breast, connects with a lactiferous tube, 
so that pus may, on suction, escape from the nipple. If this occur, 
of course, lactation should be interdicted, until pure milk is ob- 
tained. Pus in the milk can sometimes be detected by the naked 
eye. It presents a yellowish or greenish color, occurring in streaks, > 
when not intimately mixed with the milk. When it is intimately 
mixed, and in small quantity, it cannot be detected by the naked 
eye, but the microscope reveals the pus globules. M. Donne relates 
a case in which he discovered pus globules by the microscope, 
although there were at first no other evidences of an abscess, and 
doubts were expressed in reference to the accuracy of his observa- 
tion. Finally, an abscess pointed and discharged. 

Sometimes, when the inflammation abates, the secretion does 
not return, and, worse still, occasionally the inflammation has 
occurred so near the nipple that the lactiferous tubes are perma- 
nently closed by it, so that, though milk forms in the breast, there 
is no escape for it. Thenceforth lactation must be entirely from 
one breast. 

Facts and Rules in reference to Lactation. 

The new-born infant should nurse every hour, or every second 
hour, during the day. At night, if the mother is delicate, and her 
3 



34 



LACTATION. 



milk not abundant, it may be fed, once or twice, with a little cow's 
milk. It is better to select, for this purpose, the upper third of 
the milk, after it has stood two or three hours, and use it diluted 
with twice the quantity of water. If the mother is robust, she 
should not feed the infant, but allow it to nurse once or twice dur- 
ing the night. No nursling, in ordinary health, really requires the 
breast more than once during the hours which the mother needs 
for rest ; and by a little perseverance on her part its habits may be 
so established that it is satisfied if it receives the breast no oftener. 
Many young mothers commence the duty of suckling with too 
much ardor. Exerting themselves to the utmost for the good of 
their offspring, they are awake, night after night, giving their 
breast at every cry, till they find that their strength is failing, and 
with it, also, their milk. Their self-devotion necessitates early 
weaning, whereas, had they exercised more regard for their own 
health, and learned to hear with composure the cries, which often 
do not indicate any bodily want or distress, they might continue 
to suckle their infants during the usual period. 

The milk secreted during gestation, and immediately after the 
birth of the infant, differs in its gross appearance, as well as che- 
mical and microscopical characters, from that which is ordinarily, 
secreted in a state of health. It is termed colostrum. It has a 
turbid and yellowish appearance, and is somewhat viscid. It is 
decidedly alkaline, and undergoes lactic acid fermentation more 
readily than common milk, and it also contains more solid matter. 
It has an excess of fat, of salts, and, according to Simon, also of 
sugar. It appears, from Simon's analysis, that the solid matter of 
colostrum is about seventeen per cent., while that of the ordinary 
breast-milk is about eleven per cent. 



Oft o °a °° 


CO ^0 O o ° » C Q 


O o° • SwJ %® 




Milk Globules. 




Colostrum Corpuscles. 



Examined by the microscope, the colostrum is seen to contain 
oil globules and a viscid substance, which often assumes an ovoid 
or globular form, but which also exists in irregular masses of con- 



FACTS AND RULES IN REFERENCE TO LACTATION. 35 

siderable size. This substance has been thought by some to be 
mucus, but it is dissolved by acetic acid and potash, and is tinged 
yellow by a watery solution of iodine. It is, therefore, to be 
regarded as albuminous. Imbedded in this substance are oil edo- 
bules, which are for the most part of small size, while the free oil 
globules of colostrum are larger than those occurring in healthy 
milk. This viscid substance, with the imprisoned oil globules, 
constitutes what has been designated the "colostrum corpuscles." 
Some have erroneously considered the "colostrum corpuscles'' to 
be compound granular cells. The compound granular cell, or cor- 
puscle, is a cell which has undergone fatty degeneration. It is 
distended with oil globules to perhaps twice or thrice its normal 
size. On the other hand, examination of the "colostrum corpus- 
cles" fails to detect a cell-wall, and the large and irregular size of 
some of these corpuscles negatives the idea that they are cells. 
The oil globules contained in the viscid substance are more readily 
acted on by ether than are the free oil globules. 

The colostrum is replaced by milk of the normal character, in 
six to eight days ; sometimes as early as the third or fourth day 
after delivery. In exceptional instances, the colostrum does not 
disappear for several weeks, and it may reappear at any time dur- 
ing lactation, as a consequence of derangement of the system, or 
from disease. It is assimilated with difficulty by the digestive 
organs of the infant, producing usually a laxative effect. It, there- 
fore, aids in the removal of the meconium, and being a normal 
secretion in the first week of lactation, it is to be regarded as bene- 
ficial. Continuing longer than the first week, its effect is delete- 
rious. It produces evident derangement of the digestive organs, 
and the infant that habitually nurses it, never thrives. It has 
diarrhoea or vomiting, becomes more or less emaciated, and suffers 
from colicky pains. Sometimes an extreme degree of exhaustion 
is reached before the cause is suspected, for, if the milk is pretty 
abundant, the admixture of colostrum with it cannot be detected 
by the naked eye. The microscope alone reveals it. The following 
is an interesting example of this fact. In 1868 an infant six weeks 
old was brought to me, with the following history. The mother 
had for years been troubled more or less with dyspeptic symptoms, 
but had otherwise been in good health. The infant at birth was 
fleshy and strong, but after the first week it had never thriven like 
other infants. It nursed regularly, and the quantity of milk was 
apparently sufficient, but it vomited as soon as it ceased nursing ; 
it was much emaciated, and the bowels were habitually constipated. 



36 LACTATION. 

The digestive organs of the infant had been in this unhealthy state, 
with little variation, from the first week, and it was very evident, 
from the emaciation and exhaustion, that it must soon perish, 
unless some change were effected. The milk of the mother presented 
the usual appearance to the naked eye, but under the microscope 
colostrum corpuscles were observed. A wet-nurse was immediately 
obtained, and from that moment the gastro-intestinal symptoms 
disappeared, with a rapid recovery. This case shows at once the 
evil effects of the colostrum, and the need of a microscopic exami- 
nation of the milk whenever the nursling suffers from lactation. 

Human Milk. 

The specific gravity of human milk is about 1032. It ha,s been 
carefully analyzed by different chemists, with nearly the same 
result. The following table, prepared by MM. Vernois and Bec- 
querel, gives the proportion of the various ingredients in 1000 
parts : — 

Water 889.08 

Sugar 43.64 

Caseuui and Extractive 39.24 

Butter 26.66 

Salts (ash) 1.38 

1000.00 

Milk being the sole food of early infancy, contains all the nutri- 
tive principles which are required for the growth and repair of the 
different tissues. The caseum is an albuminous principle, the butter 
and sugar are combustible substances, and most of the salts which 
occur in the different tissues exist primarily in the milk. Phos- 
phate of lime, phosphate of magnesia, phosphate of the peroxide of 
iron, chloride of potassium, chloride of sodium, and soda, known 
to exist in cow's milk, are believed to occur also in human milk. 
Epithelial cells are sometimes present, derived from the lining 
membrane of the lactiferous tubes. 

Modifications of the Milk in Consequence of the Diet. 

Fresh milk should give an alkaline reaction, but in certain states 
of ill health, or after the use of certain articles of food, the reaction 
is acid. Mothers are well aware of the ill effects, as regards the 
infant, which follow their use of indigestible, or acescent food ; 
and, if prudent, they avoid it. The milk, if the diet of the mother 
is improper, may become so strongly acid as to cause colicky pains 



MODIFICATIONS OF MILK IN CONSEQUENCE OF DIET. 37 

and diarrhoea. The following observations in reference to cow's 
milk are instructive. We may infer from them that the regimen 
of the mother exerts a decided influence on the alkalinity of her 
milk. According to Routh [Infant Feeding, page 285), stall-fed 
cows almost always give acid milk. Dr. Mayer, of Berlin, exam- 
ined the milk from a considerable number of cows, with the follow- 
ing result : — 

(a.) Of cows fed with brewers' lees, red potatoes, rye bran, and 
wild hay, in five instances the milk was slightly sour ; in one very 
much so. 

(6.) Of forty cows fed with potato mash, barley husk, and clover 
and barley straw, in ten, which were examined, the milk was sour; 
in three very sour. 

(c.) From among fifty cows fed on potato husks, barley husks, 
and wild hay, five were examined, and in all the fresh milk was 
sour. 

(d.) From forty-two cows fed on potato mash, husks, wild hay, 
and rye straw, out of twelve selected for examination, the fresh 
milk of all was sour. 

(e.) From six cows fed by a chief gardener on coarse beet-root, 
red potato, bran mash, and hay, the fresh milk was slightly sour. 

(/.) From fiYQ cows fed by a cow-feeder on lukewarm bran mash 
and hay, in four the fresh milk was quite neutral, in one it was 
decidedly alkaline. (Houth.) 

The above observations of Dr. Mayer were made in the winter 
season, and it is possible that the acidity may have been partly due 
to the confinement of the cows in stalls. But that it was mainly 
due to the food is evident from the fact that it was greater with 
some kinds of food than others. Cows' milk is not so alkaline as 
human milk, and is therefore more readily rendered acid. Still, 
what Dr. Mayer observed in reference to the cow exemplified a fact 
of general applicability, namely, that certain kinds of food may 
affect the alkalinity of the milk, whether human milk or that of 
animals. 

The relative proportion of the different ingredients of the milk 
varies according to the diet. If the diet is poor, the amount of 
water increases, and that of butter and caseum diminishes. Leh- 
mann says (Phys. Chemistry, vol. ii. p. 65): "From experiments 
made on bitches, it would appear that a vegetable diet renders the 
milk richer in butter and sugar ; while the solid constituents are 
augmented when a sufficient quantity of mixed food is given. 
Peligot found the milk of an ass most rich in casein when the 



88 LACTATION. 

animal had been fed on beet-root ; whilst, it was richest in butter 
when the food had consisted of oats and lucerne. Fat food in- 
creases the quantity of the butter. Boussingault found the milk 
of a cow richer in casein when the animal had been fed on potatoes 
than when other food was taken. Reiset found that the milk of 
cows which were at grass was much richer in fat than when the 
animals had stood all night in their stall without food ; but Play- 
fair found, on the contrary, that the quantity of butter in the milk 
increased during the night as much as during their stall-feeding, 
but that the quantity of butter in the milk was considerably dimin- 
ished by the motion of the animals in the fields." 1 Simon made 
the following analyses of the milk of a poor woman. She was 
suddenly, during the period of lactation, deprived of the means of 
support, so that her food was insufficient in quantity, and of poor 
quality. The amount of her milk was not diminished by priva- 
tion, but the solid constituents were reduced to 86 parts in 1000. 
After this, for a time, her diet was nutritious and abundant, the 
quantity of milk was increased, and the solid constituents amounted 
to 119 parts in 1000. Her diet was again reduced, with a reduction 
of the solid elements to 98 in 1000, and, at a later period, the diet 
was again nutritious, with an increase of the solid elements to 126. 
The chief variation observed in the milk of this woman was in the 
amount of butter. 

Modification of Milk from its Retention in the Breast. 

M. Peligot has clearly demonstrated, that the longer milk is 
retained in the breast the more watery it becomes. This is ex- 
plained on the supposition that the solid portion is first absorbed. 
Therefore, the milk is richer the more frequently it is removed 
from the breast. A similar fact, which has the same explanation, 
has long been known, namely, that the first milk taken from the 
breast is thinnest, while that which flows last is richest. That 
first removed has remained longest in the gland, while that which 
comes last is but recently secreted. 

A knowledge of this fact is of considerable practical importance. 
The milk, as M. Donne has shown, may be too rich, so as to cause 
indigestion, with more or less enteralgia, in the infant. Some 
nurslings, if the milk is too rich and abundant, reject a part of it 
by vomiting, but others do not, and suffer the consequence in de- 

1 Animal Cliem., Sydenham Soc.'s Trans., vol. ii. p. 55. 



MODIFICATION OF MILK BY NERVOUS IMPRESSIONS. 39 

rangement of the digestive organs. For such cases the remedy is, 
to give the breast less frequently, by which a less amount of milk 
is taken, and milk of a poorer quality. On the other hand, if there 
is poverty of the milk, and the infant is insufficiently nourished, the 
milk is more nutritious if the nursing be at short intervals. 

Modification of Milk by Age and by Nervous Impressions. 

The composition of the milk varies, also, according to the age 
of the infant. Simon analyzed the milk of a woman at intervals 
for the period of about six months. In this case the amount of 
casein at first was small, but the quantity increased during the two 
months succeeding delivery, after which it was nearly stationary. 
A similar increase was observed in reference to the saline sub- 
stances. The sugar, on the other hand, diminished in quantity as 
the infant grew older, its maximum amount being in the first and 
second months. The quantity of butter in the milk varies from 
day to day more than the other elements. 

Many observations have been published which show that the 
composition of the milk may be materially changed by mental 
impressions. The infant has died suddenly in the act of nursing, 
after the mother had been violently excited. Such a case is related 
by Tourtnal. The infant ceased nursing, gasped, and died in the 
mother's lap. In other cases convulsions have occurred. MM. 
Becquerel and Vernois made the chemical analysis of the milk of 
a woman in a state of nervous excitement, and found that the 
solid constituents were diminished to 91 parts in 1000, the most 
marked diminution being in the butter, which was only about 5 
parts. In a case related by Parmentier and Deyeux the milk 
became watery and viscid, and remained so till the nervous at- 
tacks, from which the patient suffered, had ceased. Dairymen 
are well aware how ill-treatment and the separation of the calf 
from the cow diminishes the milk which she yields. A new milk- 
man seldom obtains as much milk as one with whom the cow is 
familiar. Bouchut, alluding to the influence of the moral affec- 
tions on the secretion of milk, makes the following remark, the 
truth of which most mothers will acknowledge : " It is also a fact, 
that the sight of the nursling, the idea of seeing it at the breast, 
and the joy which certain mothers thence experience, exercise a 
moral influence over the secretion of the milk entirely independent 
of their will. They feel the draught of milk as soon as they behold 
their child, or think of it too deeply ; and in a woman who saw 



40 LACTATION. 

her child fall to the ground, the flow of milk ceased, and did not 
reappear until the child, having quite recovered, attempted to 
take the breast." 

Modification of Milk by the Catamenial Function and Pregnancy. 

The catamenia reappear in most women before the close of lacta- 
tion, often by the fifth or sixth month after delivery. If this 
function is re-established in the normal manner, that is, without 
any derangement of the system, without pain or undue profuse- 
ness, no unfavorable result ordinarily occurs with the infant. On 
the other hand, if the mother suffer any disturbance of the system, 
or if the menses are profuse, the lacteal secretion may be so changed, 
that the infant is injuriously affected by it. The symptoms pro- 
duced are those of indigestion, such as abdominal pains, more or 
less vomiting, and diarrhoea. This result is, however, in my ex- 
perience, quite exceptional. In rare, instances, more dangerous 
symptoms occur in the infant. A case has been reported to me in 
which, at each catamenial period, the nursling was seized with 
convulsions. 

MM. Becquerel and Vernois have investigated the character of 
the milk during the catamenia in three cases. Their examinations 
showed a moderate increase in the solid constituents. The butter 
and caseum were increased, while the sugar was diminished. The 
variation from normal milk was not, however, such as would be 
likely to cause any serious indisposition. If the menses reappear 
with regularity, when the infant has attained the age of ten or 
twelve months, they should be considered as designed to supersede 
the secretion of milk, which, indeed, usually begins to diminish. 
Weaning is then proper. If the menses return early in the period 
of lactation, and give rise to symptoms in the infant in consequence 
of the altered quality of the milk, it is advisable to allow but little 
nursing during the catamenia, and to employ artificial feeding in 
place till the flow of blood ceases. 

The change produced in the milk by pregnancy is, in general, 
more injurious to the nursling than that caused by the reappear- 
ance of the menses. The milk of the pregnant woman is apt to 
contain more or less of that viscid substance which characterizes 
colostrum. Still, the milk of pregnancy does not, ordinarily, de- 
range the digestive function as much as colostrum, in the first 
weeks of lactation, for pregnancy rarely occurs till after the infant 
is five or six months old, when the organs of digestion are less 



QUANTITY OF BEEAST MILK REQUIRED BY INFANT. 41 

readily disturbed. The injurious effect of pregnancy on the infant 
is shown by vomiting or diarrhoea, by restlessness and occasional 
abdominal pains, in fine, by symptoms of indigestion. In many 
cases, however, these symptoms do not occur, and the infant, though 
nursing regularly, continues to thrive. IsTo doubt, as a rule, the 
infant should be weaned when there are clear evidences of preg- 
nancy, but under certain circumstances weaning is injudicious. I 
have, on different occasions, been called to infants, in midsummer, 
dangerously sick with diarrhceal attacks induced by this cause. 
These infants were, perhaps, doing well, or suffering but little from 
indigestion, when the mothers suspecting themselves pregnant, at 
once withdrew them from the breast, and cholera infantum or a 
kindred disease was the result. E"o infant in the city should be 
weaned in the hot months. It is much safer, though there are 
indubitable signs of pregnancy, that it continue nursing till the 
cold weather. The better method is, however, under such circum- 
stances, to employ a wet-nurse, or to remove the infant to the 
country, and wean it there. In cold weather, it is usually safe to 
wean an infant, in the city, after it has reached the age of five or 
six months. 

The milk frequently contains other ingredients in addition to 
those which have been mentioned. Thus a large number of medi- 
cinal substances, taken by the mother, may enter the milk, so as to 
produce their characteristic effect on the infant. It is a well-known 
fact, that the peculiar flavor of certain vegetables, taken as food, 
may be noticed in the milk. It is admitted, also, that the specific 
virus of the contagious diseases, at least certain of them, may enter 
the milk, so as to give rise to the same diseases in the infant. 

Quantity of Breast Milk required by the Infant. 

In a paper published by Dr. "W. H. Cumming, in the American 
Journal of Medical Science, July, 1858, it is estimated that the 
amount of milk secreted per day by a healthy women is one and 
a half to two quarts, and double the quantity if two infants are 
suckled. Routh (Infant Feeding, page 87) believes that this is a 
somewhat exaggerated statement. He estimates the amount at a 
quart to a quart and a half daily. " A three months child," says 
he, " generally thrives very well on four, or, at the most, five meals 
a day, the quantity taken each time amounting to a half-pint. This 
would -Q.X. the quantity at two pounds to two and a half, i.e., thirty- 
two to forty fluidounces. ... A younger child, one to two months, 



42 LACTATION". 

may need to take his meals more frequently — it may be every two 
hours, except when asleep — but then the quantity consumed does 
not exceed, as a rule, as I have often assured myself, two wine- 
glasses or three ounces every meal. This would raise the quantity 
taken in twenty-four hours to thirty-six ounces — a quart and a 
quarter. A child above three months may take about forty-eight 
ounces daily." 

Dr. Cumming, in consequence of his high estimate of the amount 
of milk which an infant requires, naturally concludes that few 
mothers can long endure the excessive drain upon their systems, 
and therefore, in order to prevent their exhaustion, and to satisfy 
the appetite of their infants, it is necessary, at an early period, to 
aid by artificial feeding. This opinion may do harm, since artificial 
feeding of the young infant, especially in the cities, is apt to give 
rise to indigestion, followed by vomiting and diarrhoea. The mother 
in good health, and furnishing an average quantity of milk, is 
competent to give all the nutriment which the infant requires 
until it has reached the age of four months, and most are till the 
age of six months. Drs. Merei and Whitehead examined 952 
mothers in the Children's Hospital at Manchester, in reference to 
their physical condition. Of these, 629, or 66 per cent., were in a 
healthy and robust state. Of this number, namely 629, 420 fur- 
nished sufficient milk till six months after delivery, and some till 
two years. 

Differences in Suckling Women as regards Quantity and Quality of Milk. 

There is, however, a great difference, in different women, as 
regards the quantity and quality of their milk, and even the mode 
in which it is secreted. The best wet-nurses are usually robust 
without being corpulent. Their appetite is good, and their breasts 
are distended from the number and large size of the bloodvessels 
and milk-ducts. There is but a moderate amount of fat around 
the gland, and tortuous veins are observed passing over it. Such 
nurses do not experience a feeling of exhaustion and do not suffer 
from lactation. 

The nutriment which they consume is equally expended in their 
own sustenance and the supply of milk. There are other good 
wet-nurses who have the physical condition which I have described, 
but whose breasts are small. Still, the infant continues to nurse 
till it is satisfied, and it thrives. The milk is of good quality, and 
it appears to be secreted, mainly, during the time of suckling. 



SCANTINESS OF MILK. 43 

Other mothers evidently decline in health during the time of lac- 
tation. They furnish milk of good quality and in abundance, and 
their infants thrive, but it is at their own expense. They them- 
selves say, and with truth, that what they eat goes to milk. They 
become thinner and paler, are perhaps troubled with palpitation, 
and are easily exhausted. They often find it necessary to wean 
before the end of the usual period of lactation. There is another 
class whose health is habitually poor, but who furnish the usual 
quantity of milk without the exhaustion experienced by the class 
which I have just described. The milk of these women is of poor 
quality. It is abundant, but watery. Their infants are pallid, 
having soft and flabby fibre. All these kinds of wet-nurses are 
met in practice. 

Occasionally, a considerable part of the milk is lost by oozing 
from the breast. This sometimes occurs in robust women, but it 
is more frequently associated with weakness. It is then due to a 
relaxed state of the orifices of the milk-ducts. Galactorrhea, as 
the excessive secretion and flow of milk is designated, is said to 
be often associated with a menorrhagic diathesis ; that is, women 
whose menses have been profuse are apt to have too abundant a 
flow of milk corresponding with the menorrhagia. It is said that 
galactorrhcea is also apt to occur in those who are subject to dis- 
charges from parts which sustain no immediate relation to the 
breast, as in cases of hsemorrhoidal flux, diabetes insipidus, etc. 
Excitement, or irritation of the uterus or ovaries, may serve as 
an exciting cause of galactorrhcea in those predisposed to it, and 
excessive suckling may have the same effect. 

Scantiness of Milk; its Causes and Treatment. 

Though the amount of breast-milk which the infant requires is 
less than was estimated by Cumming, still insufficiency of this 
secretion is not uncommon, especially in the cities. According to 
the statistics of Drs. Merei and Whitehead, among healthy mothers 
there is insufficiency in 16.5 per cent., while among mothers in 
feeble health the percentage is 46.6. In treating of this subject 
in the following pages, reference is not had to those cases in which 
there is temporary diminution of milk from acute disease or other 
perturbating causes, but to those cases in which there is habitual 
scantiness. 

One cause of scanty secretion of milk is a life of privation or of 
daily work, which necessitates separation from the infant. Insuf- 



44 LACTATION. 

ficient food may render the milk more watery, as has already been 
stated, or it may cause diminution in its quantity. The mother 
thus situated is pallid. She is subject to palpitation and attacks 
of faintness. Her condition, indeed, is that of anaemia. "Working 
women have scantiness of milk, not only in consequence of hard- 
ships, but also because they are usually separated for hours from 
their infants. Age is also a cause of scantiness of milk. Mothers 
at the age of forty years ordinarily furnish less milk than between 
twenty and thirty. And those who have not borne children till 
late in life, and whose mammary glands have therefore long been 
inactive, have less milk than those who commence bearing children 
at the usual period. 

Routh speaks of hyperemia as a cause of defective lactation. 
" This is a variety," says he, " which I have chiefly observed among 
hired wet-nurses, selected from the poorer classes, and admitted 
into wealthier families. . . . "When feeding at the expense of a 
master or mistress, the amount they devour often surpasses all 
moderate imagination. They, in fact, gormandize. If in such 
instances a wet-nurse is given all she asks for, she will be found 
often to eat quite as much as any two men with large appetites ; 
and, as a result, she becomes gross, turgid, often covered with 
blotches or pimples, and generally too plethoric to fulfil the duties 
of her position. The plethora, as first induced, is of the sthenic 
variety, but it soon assumes an asthenic character, and, as the im- 
mediate result, the breast no longer secretes its quantum of milk. 
There may be good milk secreted, but it is in small quantity, and 
this quantity diminishes daily. The breast may also enlarge, but 
it is from a deposition of fatty tissue in and about it, as in other 
parts of the body. The veins on the surface become less apparent, 
always a bad feature in a suckling breast, till finally the flow of 
milk ceases altogether." 

Atrophy of the breast from the employment of iodine, or from 
long disuse, is also a cause of insufficiency of milk. 

It is so necessary for the health and development of the infant 
that the milk should be in proper quantity as well as quality, that 
it is proper in a work of this kind to consider the treatment of 
insufficient secretion, and, on the other hand, of excessive secretion 
and loss of milk, or galactorrhea. And first of insufficient or 
scanty secretion. 

The most efficient mode of increasing the lacteal secretion is 
that which is also natural, namely, suction from the nipple. There 
are many cases on record in which this has produced the flow of 



SCANTINESS OF MILK. 45 

milk in women who have never borne children, and even in men. 
Baudelocque mentions the case of a girl, eight years old, who 
suckled her brother for a month, and cases at the opposite extreme 
of life have been reported; one of a woman of seventy years, who 
wet-nursed a grandchild twenty years after her last confinement. 

Travellers among barbarous nations or tribes have often observed 
these cases of unnatural lactation. Humboldt saw a man, thirty- 
two years old, who gave the breast to his child for five months, and 
Captain Franklin, in the Arctic regions, met a similar case. Dr. 
Livingstone, in his account of Africa, says that he has examined 
several cases in which a grandchild has been suckled by a grand- 
mother, and equally remarkable instances of lactation occur among 
the negroes of the Southern and Middle States. Prof. Hall pre- 
sented to his class in Baltimore a male negro fifty-five years old 
who wet-nursed all the children of his mistress. In these cases 
of abnormal lactation, so far as we have complete records of them, 
it is ascertained that the breasts were torpid, and even sometimes, 
as in old people, atrophied till the nursing commenced. Titil- 
lation, or pressing of the nipple, caused an afflux of blood to the 
gland, and developed its functional activity, so that milk was pro- 
duced for the sustenance of the nursling. Therefore, in case of 
scanty secretion of milk, the mother may increase the quantity by 
applying the infant often to the breast. If, dissatisfied with the 
small amount of nutriment which it receives, it refuses to make 
the necessary suction, any other mode of gentle traction or pres- 
sure may be employed in addition. The occasional employment of 
another infant, or a pup, milking the breast with the thumb and 
fingers, or the gentle suction of a breast pump, aids in stimulating 
the secretion. Forcible rubbing or traction of the breast defeats 
the purpose for which it is employed. It produces too much irrita- 
tion and tenderness. The best mode of stimulation is by nursing, 
as it is the natural mode, and the moral effect of the infant at the 
breast aids in promoting the secretion. 

Another mode of increasing the functional activity of the mam- 
mary glands is by the electrical current. The fact is established by 
physiological experiments, that glandular organs can be made to 
secrete more actively by the stimulus of electricity, and, accord- 
ingly, this agent has been successfully employed to promote the 
secretion of milk. In Eouth's Infant Feeding several cases are 
related which show the beneficial effects of this agent (page 149 
et seq.). Among them are six reported by Dr. Skinner, of Liver- 
pool. In all these, one or two applications of the electrical current 



46 LACTATION. 

sufficed to restore the secretion. The following is Dr. Skinner's 
mode of employing this treatment : — 

" 1. Direct. — Both poles must terminate in cylinders, with sponges 
well moistened in tepid water. The positive pole is pressed deep 
into the axilla, while the negative is lightly applied to the nipple 
and the areola ; the current being no stronger than is agreeable to 
the patient's feelings. The poles are kept in this position for about 
two minutes. Both poles are then to be inserted into the axilla, 
and gradually brought together, the negative to the sternal, and 
the positive to the opposite of the organ. This latter step may 
occupy one or two minutes more. 

" 2. Intramammary. — The poles are to be, as it were, imbedded 
in the mamma, and moved about, raising and depressing both poles 
at once in and around the organ for the space of another two 
minutes. The same is to be done to both breasts daily, until the 
secretion is properly established. Hitherto one or two sittings 
have always sufficed in my hands." {Communication of Dr. Skinner 
to Dr. Houth.) 

In all cases of scanty secretion of milk, the regimen of the mother 
is a matter of importance. Personal and domiciliary cleanliness 
is essential for successful wet-nursing. A certain amount of ex- 
ercise in the open air is conducive to the health of the mother, and 
to the secretion of abundant and healthy milk. A case is related 
to show the effect of fresh air and out-door exercise on the lacteal 
secretion. A lady of cleanly habits, living in London, had a very 
scanty supply of milk. She removed to the pure air of the sea- 
shore, and immediately the quantity became abundant, and con- 
tinued so for months. Such cases are not unfrequent. A mode of 
life that contributes to the general health of the mother will not 
fail to augment the quantity of her milk, if it is scanty, and to 
improve its quality. 

Much has been written in reference to the diet of women who 
suckle. It is a popular belief that certain articles of food promote 
the secretion of milk much more than other articles, though equally 
nutritious. No doubt, writers have erred in recommending exclu- 
sively this or that kind of food, as most likely to produce milk. 
The exact kind of food which is preferable, in a certain case, de- 
pends partly on the physique of the individual, and partly on the 
character of the food to which she has been accustomed. A mixed 
diet contributes most to the sustenance of the mother, and to an 
abundant secretion of milk. Animal substances which furnish a 
due supply of nitrogenous aliment should be given with the fari- 



SCANTINESS OF MILK. 47 

naceous. Mothers pallid, and inclining to an anaemic condition, 
require a larger proportion of animal diet than those in good 
general health. On the other hand, plethoric women, such as 
Eouth describes, who with excellent appetites consume large quan- 
tities of food, and who become more and more full-blooded and 
corpulent while the milk diminishes, require a more restricted 
animal diet, in connection with more exercise, especially in the 
open air. ' 

There are certain kinds of food which do appear to have a galac- 
togogue effect with most wet-nurses. Oatmeal gruel is one of 
these. "Wet-nurses often remark, after taking a bowl of this, that 
they feel the flow of milk. Cow's milk with some has a similar 
effect. Porter or ale, taken once or twice a day, also promotes the 
secretion of milk, especially in those who have poor appetite, and 
whose systems are somewhat reduced. 

A great variety of medicines have been used for their supposed 
galactogogue effect. Medicines which improve the general health 
are, no doubt, sometimes useful for this purpose, such as the vege- 
table and ferruginous tonics, and perhaps cod-liver oil. But there 
are other medicines which it is claimed have a specific effect on the 
mammary gland, promoting its secretion. Lettuce, winter-green, 
fennel, the broom tops (cytisus scoparius), marsh-mallow, castor oil 
plant, and many other plants, have been used for this purpose. 
There can be no doubt that the aromatic stimulants, as fennel, 
anise, and caraway seeds, given in soups, sometimes stimulate the 
lacteal secretion. But the medicine which of late has attracted 
most attention in the profession, as a galactogogue, is castor oil and 
the plant from which it is derived. 

The galactogogue effect of the leaves of the castor oil plant has 
been long known to the Spaniards in South America. At least as 
long ago as the commencement of the last century, the ricinus com- 
munis was applied by them externally to the breast, to promote the 
secretion of milk. It is now about twenty years since this use of 
the plant was brought prominently to the notice of the profession 
in this country and in Europe. In the London Journal of Medi- 
cine, 1857, Dr. Tyler Smith relates the results of his experiments 
with the castor oil plant. He applied the bruised leaves over the 
breasts, and witnessed, as he thinks, an evident galactogogue effect. 
Dr. Bmrth has also made pretty extensive use of the plant, both 
externally and internally. He was led, he says, to employ it in- 
ternally, from noticing, in suckling women, an increase of milk 
after taking a dose of castor oil. He prescribed a decoction of the 



48 LACTATION. 

leaves and stalks, and says : " I have not been disappointed. The 
flow has been remarkably increased. Four objections against its 
use, however, should be mentioned." These are, first, a peculiar 
sensation in the eyes, with dimness of sight, an effect which he has 
observed only in weak women ; secondly, the necessity of increas- 
ing the dose as the patient becomes accustomed to it; thirdly, 
scarcity of the plant ; fourthly, an occasional diuretic, sometimes 
without galactogogue effect, and sometimes with it. The cases in 
which diuresis occurred were in the practice of other physicians, 
and Dr. Routh conjectures that this effect was produced by not 
keeping the breast warm during the time that the decoction was 
being employed. The breasts should at the time of its use be 
covered with a fomentation of leaves, or an extract of the leaves 
should be rubbed over the breasts in the same way in which extract 
of belladonna is used, and over this a warm poultice applied of 
the ordinary material. Dr. Eouth remarks : " When the castor oil 
leaves are given as an infusion to women who are not suckling, I 
have observed two effects, both of which seem to denote its specific 
action. First, it produces internal pain in the breasts, which lasts 
for three or four days. Then, secondly, a copious leucorrhoeal dis- 
charge takes place, after which the effect on the breasts entirely 
disappears." 

Dr. Grilfillan, of Brooklyn, has also employed the ricinus com- 
munis successfully as a galactogogue. He employed a poultice of 
the pulverized leaves, and gave internally the fluid extract of the 
leaves, a teaspoonful three times daily. The patient had been con- 
fined the year before with her first child, but had no milk for it, 
though her health was good, and measures were employed, as fric- 
tion and fomentations, to stimulate the secretion. The ricinus was 
prescribed the fourth day after her confinement with the second 
child, when there were no signs of secretion, and the breasts were 
small. "About two hours after the poultice was applied, and the 
first dose taken, she experienced a strange sensation in the breasts, 
and this increased after each dose of the medicine. The poultice 
was not renewed, but the extract was continued for three days, 
after which lactation was perfectly successful." So far observations 
have shown that the ricinus is the most efficient galactogogue which 
we possess among medicinal agents. 

In the treatment of galactorrhea the object to be attained should 
be kept in view. There are medicines which cure this affection by 
diminishing the amount of milk. Belladonna, iodide of potassium, 
and colchicum are antigalactics. It is proper to use them in case 



SELECTION OF A WET-NURSE. 49 

of weaning or of death of the infant. They not only reduce the 
quantity of milk, but, continued, may prevent its secretion. They 
are employed not to benefit the infant, but the mother. 

On the other hand, if it is our purpose to prevent the oozing of 
milk in order to save it for the infant, or, if it is abundant and 
watery, to diminish somewhat its quantity and improve its quality, 
the treatment should be different. Iron, in cases of galactorrhea, 
in which the condition of the system appears to indicate the need 
of it, will diminish the quantity of milk and render it richer. It 
is by many regarded as an anti galactic, and given long it might 
reduce too much the amount of the secretion, and even necessitate 
weaning. Its use should be discontinued if no more than the 
normal amount of milk is secreted. 

In most cases of true galactorrhea the pathological state is that 
of weakness and relaxation of the tissues. The fault is not exces- 
sive secretion of milk so much as its non-retention, and the medi- 
cines which are the most useful to correct this state of the system 
and of the breasts are the vegetable tonics and astringents. If 
galactorrhea occur in those who have an habitual discharge, and 
it appears to be due to the same cause which produces that dis- 
charge, and there are no evidences of weakness, laxative medicines 
and other derivatives may be employed. But such cases are not 
common. £Tux vomica has been recommended in galactorrhea, in 
the belief that it diminishes the relaxation of the orifices of the 
lactiferous tubes. 

Local treatment in this affection is important. A cloth wrung 
out of cold water should be occasionally applied around the nipple, 
and removed as it becomes warm. Solutions of tannin or alum are 
likewise useful. Collodion applied around the nipple, by its retrac- 
tion, diminishes the orifices of the ducts, and thus aids in the reten- 
tion of the milk. 



CHAPTER V. 

SELECTION OF A WET-NURSE. 

In the cities, cases are frequent in which mothers, with all pos- 
sible care or endeavor, find themselves unable to suckle their infants. 
Their health is too poor, or the milk possesses the properties of colos- 
trum, or it is no longer secreted on account of nervous excitement, 
4 



50 SELECTION OF A WET-NURSE. 

or exhaustion, or inflammation of the breasts. The number of such 
cases, in the city, would surprise physicians who are familiar only 
with the healthy and robust mothers of the country. The infant 
thus deprived of the mother's milk should, if practicable, be fur- 
nished a wet-nurse. 

The selection of a wet-nurse often devolves upon the physician, 
and it is a duty of great responsibility. It is better to select one 
between the ages of twenty and thirty years, and one who has 
suckled an infant previously. A wet-nurse between the ages of 
twenty and thirty is usually more active, cheerful, and conciliatory 
than one of a more advanced age, and her milk is more apt to be 
abundant and nutritious. Those who have previously suckled and 
had charge of infants are obviously more competent to serve as wet- 
nurses than are primiparse. The milk of a wet-nurse, whose infant 
is under the age of six months, will ordinarily agree with a new- 
born infant. If above that age, it sometimes agrees, but often does 
not. 

The most difficult and responsible task imposed on the physician, 
in the selection of a nurse, is to ascertain the exact condition of her 
health, and the quantity and quality of her milk. Constitutional 
syphilis is common in the class of women who present themselves 
for wet-nursing ; it is often latent, or its symptoms are easily con- 
cealed, and it is communicable by lactation. The virus may be re- 
ceived by the infant from fissures or excoriations of the nipple. The 
nursling tainted by syphilis may, on the other hand, communicate 
the disease to the nurse through the same source. It is not fully 
ascertained whether the syphilitic virus may be conveyed to the 
infant by the milk. But the cases which have accumulated in the 
records of medicine are numerous, in which infants born of healthy 
parents have been fully syphilized by lactation from diseased nurses 
(see article Syphilis). These infants have sometimes led a short 
and miserable existence, and have occasionally increased the misery 
of the household by imparting the disease to others. The duty is, 
therefore, imperative on the part of the physician to examine care- 
fully the wet-nurse, in reference to any evidences of the syphilitic 
taint. Acquainted with the symptoms of syphilis, he may usually, 
by shrewd questioning and by careful examination of the present 
appearance and condition of the woman, ascertain with consider- 
able certainty whether her system has ever been infected. Eefer- 
ences should also be obtained and consulted, and, if practicable, the 
physician who has attended her be communicated with. 



EXAMINATION" OF THE MILK. 51 

There are, also, among the women who present themselves for 
wet-nursing in the cities, many of a scrofulous habit, many who 
possess an hereditary tendency to tuberculosis, if indeed they do 
not already have the incipient disease. Such applicants should be 
rejected, on account of the poverty of their milk and the proba- 
bility that they will not be able to endure the debilitating effect of 
lactation. 

The milk should be examined, in order to ascertain its richness 
and quantity, and whether it contains colostrum. If there is colos- 
trum after the eighth day, it is probable that there is some fault in 
the health or digestion of the wet-nurse, and that her milk may 
disagree with the infant. It is not necessary that the breasts should 
be large, in order to furnish a sufficient quantity of milk, since, as 
has been already stated, in some the secretory function is active 
during the time of each nursing, so that, although the breasts are 
of moderate size, a sufficient amount of milk is furnished. The 
nipples should be well formed and prominent, and preference is to 
be given to those wet-nurses in whom vessels are seen ramifying 
over the breasts. 

By examination of the milk, its degree of richness can be readily 
ascertained. A quantity of it should be placed in a test-tube, and 
the cream, which rises to the top, indicates, approximatively, the 
character of the milk. Good milk furnishes three per cent, of 
cream, and the caseum and sugar usually correspond in quantity 
with the cream. An instrument has been invented, called the 
lactometer, by which the exact amount of the cream can be ascer- 
tained. It is simply a tube graded into 100 divisions. It is placed 
upright, and filled with milk, and the number of divisions occupied 
by the cream indicates its proportion in 100 parts. The lactoscope 
is another instrument employed for the purpose of ascertaining the 
richness of the milk. It consists of two concentric tubes, which 
move upon each other. Milk which we wish to examine is poured 
within the tubes sufficient to obscure a light viewed through it, 
three feet distant. The column of milk is then diminished, till 
the light begins to be visible. The size of the column indicates 
the degree of opacity and the richness. The lactoscope was in- 
vented by M. Donne, and is described by him. 

Dr. Minchin recommends a simple mode of determining the 
richness of cow's milk, and it would equally answer for the breast 
milk. A vessel holding about one ounce, and containing a gradu- 
ated enamel slab, passing diagonally from above downwards, is filled 
with milk. It is then covered with a glass slide carried over it in 



52 SELECTION OF A WET-NURSE. 

such a way as to exclude bubbles. The number of degrees which 
can be read, indicates the character of the milk, as regards its 
richness. 

Examination of the milk with the microscope not only enables 
us to determine whether there are abnormal corpuscles or granular 
elements, but also its richness. It should be examined before the- 
cream has separated. Oil globules of small size, and few, indicate 
poverty of the milk ; very large oil globules are said to indicate 
milk which is apt to be indigestible, especially in feeble infants. 
Such are the free globules of the colostrum. Numerous oil globules 
of medium size indicate nutritious milk. Yogel, in 1850, made the 
discovery of vibriones in human milk. The fact is established that 
these animalcules may be generated in the milk within the breast, 
though such cases are not frequent. Dr. G-ibb describes a case which 
he met. (Banking's Abstract, vol. xxxiv.) An infant, 7 weeks old, 
wet-nursed by its mother, who had the appearance of perfect health, 
was, nevertheless, ill-nourished and emaciated. It had no diarrhoea 
or other apparent disease, and the milk was therefore examined. 
Yibriones baculi were found in the milk immediately after it was 
obtained from the breast. The milk had the usual amount of 
cream, and seemed to the naked eye of good quality. According 
to Dr. Gibb, two genera of animalcules occur in the milk, namely, 
vibriones and monads. It is believed that the monads occur in 
consequence of fermentation of the sugar and the production of 
lactic acid. Yogel also attributed the production of the vibriones 
to fermentation occurring in consequence of heat and congestion 
of the breast, connected with sexual excitement. This explanation 
is probably not correct, because vibriones sometimes occur when 
there is no unusual heat of breast, and no evidence of fermentation. 
The fact that such organisms may occur in milk which seems of 
good quality to the naked eye, affords additional proof of the use- 
fulness of the microscope in the selection of a wet-nurse. 

Many wet-nurses have a return of the menses as early as the 
fourth or fifth month after delivery. The re-establishment of this 
function in some women impairs the quality of the milk, so as to 
render it less nutritious, and perhaps less digestible; in other women 
it does not sensibly affect the character of the fluid or its quantity. 
In the selection of a wet-nurse, then, preference should be given to 
one who does not have the periodical sickness, but if she is already 
employed, and gives satisfaction, the reappearance of the catamenia 
does not indicate the need of a change of nurse, unless the diges- 
tion of the infant is disordered, or its nutrition is impaired. 



EXAMINATION OF THE MILK. 53 

In the selection of a wet-nurse attention should also be given to 
her mental and moral traits. Cheerfulness, affection, veracity, and 
a proper appreciation of the responsibility of her situation enhance 
greatly the value of a wet-nurse. Not less important are habits of 
temperance and cleanliness. I could cite cases of the most melan- 
choly results from the absence of these traits. In one case idiocy 
resulted from an infant falling upon the pavement from the arms 
of a reckless or intemperate wet-nurse. 

In most cases the mode of examination indicated above suffices 
to show the character of a wet-nurse, so far as her health and milk 
are concerned. It should be borne in mind, however, that the 
microscope does not always reveal deleterious properties in the 
milk. Elements which are in a state of solution, and are invisible, 
may occur in excess, so as to impair the quality of the milk, and 
render it indigestible. The following case, in which the saline 
ingredients seem to have been in excess, is related by Dr. Hartmann 
{British and Foreign Medical Hevieiv, vol. xii.) : "An infant whose 
mother was in good health, and had borne several children, exhibited 
a healthy appearance for the first five weeks after birth. The alvine 
evacuations then became copious, fluid, and discolored, and the 
child lost flesh and strength. After the usual remedies had been 
vainly administered for a fortnight, the mother remarked that the 
child did not take the right breast willingly, and so much did 
the unwillingness increase, that at length the mere application of 
the nipple to the child's lips occasioned loud crying. On exami- 
nation it was found that the milk of the right breast had a dis- 
tinctly saline taste ; whereas the milk of the opposite breast was 
of the ordinary sweetness ; no difference of consistence or color 
was discoverable. From that time the child was only allowed to 
nurse the left breast, and in a few days all diarrhoea and sickliness 
of appearance vanished." In this case there was no appreciable 
disease of the breast, although its secretion was perverted. The 
deleterious character of the milk was discovered, not by any change 
in its appearance, but by the taste. 



54: COUESE OF LACTATION" — WEANING 



CHAPTER VI. 

COURSE OF LACTATION— WEANING. 

Regularity in nursing is required. The young infant in whom 
the milk is rapidly assimilated, may take the breast every two hours 
in the day, and two or three times in the night. Still, as M. Donne 
has said, mathematical exactness in this matter would be ridiculous. 
Quiet, natural sleep of a well-nourished infant should not be inter- 
rupted in order to give it the breast, unless the sleep be unusually 
protracted. It will usually awaken when the system requires more 
nutriment. Ill-nourished infants, according to my observations, 
sleep but little until they become much prostrated, when they are 
drowsy, in consequence of passive congestion of the brain. This 
drowsiness is evidently a pathological symptom. It shows the need 
of increased nutrition. It is due to scantiness of milk, or milk of 
poor quality, and the infant should be aroused frequently for the 
purpose of giving it nutriment or even stimulants. 

As the infant grows older the stomach receives a larger amount 
of milk, and it should nurse less frequently. The breast milk is 
sufficient for its nutrition till the age of six or eight months, pro- 
vided it is abundant and of good quality. If the mother is strong 
and experiences no exhaustion from suckling, the infant, therefore, 
need receive no other nutriment till that age, or indeed till the age 
of ten or twelve months. 

Many mothers, however, by the third or fourth month of lacta- 
tion find that they have not sufficient milk to meet the wants of 
the infant. The constant drain upon their systems sensibly impairs 
their health. In such cases it is proper to commence with a little 
feeding from the spoon or bottle, and increase the quantity given 
as the infant grows older. Great care is, however, requisite in the 
prejoaration of food for so young an infant, whose digestive organs 
are still feeble and easily deranged. In the country, where diar- 
rheal affections and the so-called gastric derangements are not fre- 
quent, the danger from artificial feeding is less than in the city, 
and in the cool months in the city the danger is less than in the 
summer season. Infants of the city, between the months of May 



COUESE OF LACTATION — WEANING. 55 

and October, have a strong predisposition to diarrhceal attacks, the 
result of anti-hygienic influences which surround them. Errors of 
diet in their case readily provoke disease or derangement of the 
digestive organs, often of a severe and dangerous form. Moreover, 
experience has shown that these infants, if fed with the bottle, 
however carefully, during the period when nature designed that 
they should be nourished by lactation, very commonly are affected 
in the hot months with more or less vomiting and diarrhoea, fol- 
lowed by emaciation and other evidences of mal-nutrition. There- 
fore, an exception must be made in case of the city infant as regards 
the commencement of artificial feeding. If it is under the age of 
one year, it should be nourished exclusively, or almost exclusively, 
at the breast during the hot months, when practicable, even if the 
mother suffers somewhat in her health from the constant drain 
upon her system. The infant should, however, receive the amount 
of nutriment which it requires, and, if there is not sufficient 
breast milk, it will be necessary to supply the deficiency by arti- 
ficial feeding. 

The subject of artificial feeding will engage our attention in a 
separate chapter. It suffices, therefore, in this connection to state 
that nursing infants of three or four months may begin to take a 
little cow's milk, carefully prepared and of the best quality. It- 
should be diluted, but the amount of dilution required obviously' 
depends on the richness of the milk. Rich country milk is suffi- 
ciently diluted, if the infant is in good health, by adding half its 
quantity of water, while most samples of milk furnished in the 
city do not require more than one-third their quantity of water. 

A little sugar of milk, which is slowly soluble, should be dis- 
solved in the water before its mixture with the milk. One drachm 
of the sugar is sufficient for fi.Ye or six ounces of the milk, and to 
the same quantity, if the stools are at all acid, two teaspoonfuls of 
lime-water should be added. An alkali taken with cow's milk 
retards the coagulation of casein in the stomach, and tends to pre- 
vent the formation of a large, thick curd in the stomach, which is 
with difficulty digested. If, therefore, the child vomits such curds, 
or passes fragments of them in the stools, a larger proportion of 
lime-water may be added, or the carbonate of soda as recommended 
by Vogel, who dissolves one drachm of the carbonate in six ounces 
of water, and adds a teaspoonful to the milk at each meal. It is 
proper, also, to allow farinaceous food to an infant of three or four 
months, if its digestive organs are in good condition. I prefer 
barley flour for this purpose to arrowroot, rice, or wheat flour. 



56 COURSE OF LACTATION — WEANING. 

Barley-water should be prepared from Robinson's or some other 
flour of good quality, and mixed while still warm with an equal 
quantity of milk, and the sugar of milk added. The barley-water 
should be of about the consistence of milk, and prepared in the 
usual way by boiling. The milk should not be boiled. It may, 
indeed, be stated, as a rule, that it is not advisable to boil milk 
designed for infants, except in the city, where it may be boiled in 
order to its better preservation. Toast-water may be also employed 
for diluting the milk, but it is less nutritious than barley-water. 
At the age of six months, if the infant is in good condition, the 
milk need not be diluted. 

As the infant grows older, semi-liquid food may be given. Pap 
prepared with stale bread, or a rolled soda-cracker, may now be 
given, once or twice daily, between the times of nursing, and occa- 
sionally beef-tea or chicken-broth, thickened with cracker or bread, 
is taken with relish, and if well prepared, and given no oftener 
than once or twice a day, it is commonly readily digested, while it 
is highly nutritious. If the quantity of breast milk diminishes, 
as it often does, towards the close of the first year, artificial food 
should be given oftener, so as to supply the deficiency. Solid food 
requires considerable development of the digestive organs for its 
ready assimilation. It should not, therefore, be given till the close, 
or near the close, of the first year. 

"Weaning ought to take place., as a rule, between the ages of 
twelve and eighteen months. It is well, if the mother's health is 
good, and her milk is sufficient, to defer weaning till the canine 
teeth appear. The infant then, possessing sixteen teeth, is able to 
masticate the softer kinds of solid food. "Weaning should be gra- 
dual. Mothers often speak of weaning on a certain day. They 
have given but little artificial "food, and have suckled at regular 
intervals, till at a fixed time they have denied the breast altogether. 
This abrupt change of diet should be discouraged. It should only 
be recommended under peculiar circumstances. It is apt to derange 
the digestive organs, and it causes fretfulness and sleeplessness on 
the part of the infant for a week or more. Weaning should com- 
mence by feeding with the spoon, a little oftener through the day, 
and nursing less, and by discontinuing the practice of suckling at 
night. The infant tolerates this gradual change of diet, while it 
rebels against sudden weaning, and by its fretfulness increases 
greatly the care and trouble of the mother. The infant in the 
city should not be weaned in warm weather, nor within a month 
immediately preceding it. If the mother's health fails or her milk 



AETIFICIAL FEEDING. 57 

becomes deficient, in the summer months, so that she cannot con- 
tinue suckling, the infant should be sent immediately to the coun- 
try, or a wet-nurse be employed. Many infants are sacrificed in 
consequence of ignorance of the clanger of weaning under the cir- 
cumstances mentioned. Severe diarrhoea, inflammatory or non- 
inflammatory, is apt to result. This subject will be considered 
elsewhere. 



CHAPTER VII. 

AETIFICIAL FEEDING. 

Occasionally the mother is unable to suckle her infant, and a 
hired wet-nurse cannot be or is not obtained. Artificial feeding is 
then necessary. In the large cities, if I may judge from our New 
York experience, this mode of alimentation for young infants 
should always be discouraged. It generally ends in death, pre- 
ceded by evidences of faulty nutrition. A considerable proportion 
of those nourished in this manner thrive during the cool months, 
but on the approach of the warm season they are the first to be 
affected with diarrhoea and other symptoms indicating derange- 
ment of the digestive function. In my opinion, based on a pretty 
extended observation, more than half of the 'New York spoon-fed 
infants, who enter the summer months, die before the return of cool 
weather, unless saved by removal to the country. In the country, 
and in the small inland cities, the results of artificial feeding are 
much more favorable. The majority live, and in elevated farming 
sections, on account of the salubrity of the air, and the facility 
with which milk, fresh and of the best quality, is obtained, arti- 
ficial feeding appears to be nearly as favorable as wet-nursing. 

Young infants, fed by the hand, obviously require food prepared 
so as to resemble as closely as possible the human milk. The 
basis of such food must, therefore, be the milk of some animal. 
The following table, prepared by MM. Vernois and Becquerel, 
gives the proportion of the ingredients of human milk, and the 
milk of the four domestic animals which is most easily obtained 
and most frequently employed as food. 



58 



ARTIFICIAL FEEDING, 



Composition of Milk. 





Specific 
gravity. 


100 parts 


contain — 


Thes 


olid components consist of — 




Fluids. 


Solids. 


Sugar. 


Butter. 


Casein and 

extractive 

matters. 


Salts. 


Man 


1032.67 
1033.38 
1034.57 
1033.53 
1040.98 


889.08 

864.06 
890.12 
844.90 
832.32. 


110.92 
135.94 
109.88 
155.10 
167.68 


43.64 
38.03 
50.46 
36.91 
39.43 


26.66 
36.12 
18.53 
56.87 
54.31 


39.24 
55.15 
35.65 
55.14 
69.78 


1.38 


Cow 


6.64 


Ass 


5.24 


Goat 


6 18 


Ewe 


7 16 







Cow's milk is most readily obtained, and is commonly used as a 
substitute for human milk, compared with which it contains less 
water and sugar, but more butter, casein, and salts. Its composi- 
tion, however, varies considerably according to the food of the cow 
and other circumstances. The variations in the milk of the cow, 
according to the nature of its food, have been considered in a pre- 
ceding chapter. It has been stated, also, that the milk first obtained 
in milking is most watery, since it is longer secreted than the last 
milk, or the " stripping." The stall-fed cow gives acid milk, while 
the cow grazing in a pasture gives milk that is alkaline. Again, 
the milk in the first months after calving is richer than after the 
lapse of several months. 

It is obvious from the above facts that the analysis of different 
specimens of cow's milk must differ greatly, and the same is true 
of the milk of the goat and ass, and probably of the ewe. In fact, 
different samples of the milk of the same animal may differ more 
from each other, in their chemical character, than the average milk 
of one animal from that of another. 

The milk of the goat and that of the ass have been recommended 
as food for infants in preference to cow's milk, on the ground, as 
is alleged, that they more nearly resemble human milk. But by 
reference to the foregoing table it will be seen that more impor- 
tance has been attached to this supposed resemblance than the facts 
justified. Neither the milk of the ass nor goat, so far as its chemi- 
cal character is concerned, would seem to possess any advantages 
over cow's milk. The ass's milk is procured with difficulty, and 
is seldom used. An objection to goat's milk is the unpleasant odor 
which it often possesses, due to the presence of hircic acid. It is 
stated, however, by Parmentier, that this odor is only noticed in 
the milk of goats that have horns. An important advantage, 
in the city, in the use of goat's milk, is that the animal can be 



ARTIFICIAL FEEDING. 59 

kept at little expense, so that even poor families who are not ahle 
to purchase and feed a cow can generally possess a goat, from which 
fresh milk can be obtained at any time. Preference is to be given 
to goat's milk when fresh, over cow's milk brought from the 
country, perhaps watered on the way, and several hours old when 
received. If, however, as both chemical analysis and experience 
show, goat's milk is no better as food for infants than cow's milk 
when fresh and from healthy cows, the latter must continue in 
common use for this purpose. 

Milk used for infants should always be alkaline. If it is acid, 
as shown by the proper test, it should be rejected; or, if there is 
none better, should be rendered alkaline by the addition of lime- 
water or carbonate of soda. The nurse should test the milk at 
different periods through the day, and be taught to make the 
necessary addition. M. Donne prefers the first milking, when it 
is possible to obtain it. This contains a smaller proportion of solid 
elements than the average milk, bears a closer resemblance in its 
chemical character to human milk, and requires but little dilution. 
The upper third of the milk, after it has stood two or three hours, 
is also preferable, as the casein, which is digested with more diffi- 
culty than the other elements, has a high specific gravity and tends 
to settle towards the bottom. If the infant is under the age of 
two or three months, the milk should be diluted with one-third 
or one-half its quantity of water. After the age of three or four 
months, it requires no dilution. It should always be given at 
a uniform temperature, namely, a little warmer than the body. 
Employed habitually too hot or too cold, it is apt to cause stoma- 
titis, if not more serious disease of the digestive organs. 

After the fourth month, the infant may be allowed crushed soda 
cracker, or stale bread upon which boiling water is poured and 
then drained off, and afterwards milk added. Porridge made with 
rice, barley flour, or arrowroot is also a proper article of diet at 
this age. After the fifth or sixth month, milk with crumbled soda 
cracker or stale bread may also be allowed. 

The shops contain various preparations of food for infants, and 
most of them have been employed in the institutions of this city 
sufficiently to ascertain their effects. The one which has given 
most satisfaction is known as Pestle's Lacteous Farina, prepared 
by Henri Nestle, a Swiss chemist. It is preferred in the Nursery 
and Child's Hospital, and Infant's Hospital, to Liebig's Soup, but 
the latter, so highly extolled by the German physicians, and a 
description of which will be found in the appendix, may not have 



60 BATHS — CLOTHING. 

been well prepared in these institutions. Pestle's food is, however, 
expensive, and although infants thrive well on it in the cooler 
months, I am of opinion, from my own observations, that in the 
hottest weather, when diarrhoeal affections are so prevalent and 
fatal, it has too laxative an effect. I do not, therefore, recommend 
as the ordinary diet of healthy infants any other food than the 
mother is able to prepare readily, with milk, or, under certain cir- 
cumstances, barley-water, as its basis. 

In the first half year it is most convenient and otherwise prefer- 
able to give the food through a sucking-bottle, after which the 
infant may be fed with a spoon, or taught to drink from a cup. 
The physician should positively forbid the use of sugar teats and 
various sweetened admixtures which nurses are so apt to em- 
ploy, as they tend to produce simple stomatitis, sprue, and, if much 
employed, even indigestion and diarrhoea. 

Between the ages of one and two years the teeth have become 
sufficiently developed for the mastication of light food. Tender 
and finely cut meat, potato baked and mashed, bread and butter, 
and even certain fruits carefully selected, may then be allowed. 
After the age of two years less rigid surveillance of the food is 
required, but the variety is sufficient if all dishes except the most 
bland and unirritating are excluded till after the first years of 
childhood. The reader is referred to Appendix A for various 
dietary formulae and directions relating to the choice and prepara- 
tion of food, which will be found useful in the treatment of young 
children, in those diseases especially in which the digestive func- 
tion is seriously impaired. 



CHAPTER VIII. 

BATHS— CLOTHING. 

Daily ablution of the infant conduces to its comfort and health. 
If under the age of two months, it should be bathed daily in water 
of about the temperature of 92°. As it grows older the tempera- 
ture should be gradually reduced, a bath at 88° to 90° being proper 
for an infant between the ages of three and six months, and one at 
86° for an infant between six and twelve months. In the second 
and third years the temperature of the bath should be about 84°. 
After the bath, which should continue from five to ten minutes, 



BATHS — CLOTHING. 61 

the surface should be gently rubbed with a soft towel to produce 
reaction and a glow of the skin, which would prevent danger of 
taking cold. 

The clothing of children, especially in our variable climate of 
the north, is a matter of importance, and one in regard to which 
the parents often require instruction. It may be stated, as a rule, 
that the chest and abdomen of the infant should be so covered with 
flannel that there is no danger of producing chilliness by a sudden 
reduction of the external temperature or exposure to a current of air. 
Ey this precaution many cases of laryngitis, bronchitis, and diar- 
rhceal affections, now so common in infancy, might be avoided. In 
winter the flannel should be thick, and in the summer thin. Even 
in the hottest weather the abdomen should have a light flannel 
covering, which increases the comfort, if the surface is in the nor- 
mal state. If lichen, which is not uncommon in the warm months, 
appear upon the surface, I would not remove thfe flannel, but place 
under it linen or soft muslin. 

The popular idea that children may be hardened by exposure 
to the weather in scanty clothing, and by being bathed, even at 
the most tender age, in water at so low a temperature as to pro- 
duce chilliness, cannot be too strongly combated. The hygienic 
management of the child should always be such as insures present 
comfort. If it do not, if it is regarded with aversion and dread 
by the child, the method is wrong. 

The dress should always be so loose as to allow free movements, 
and not embarrass in the least any of the functions. This is a 
matter which is left too much to the discretion and intelligence of 
the nurse, who is usually so ignorant of the important facts in 
physiology that she unwittingly, and with the best intentions, in- 
jures her charge. I have often interposed "to loosen the dress of the 
new-born, which was so tight as to sensibly embarrass respiration ; 
and one case has been reported to me in which it appeared that 
death resulted from this cause. Infants, especially, who are so 
liable to pulmonary collapse and intestinal hernias, should have 
loose covering of both chest and abdomen. 

The feet of children should always be warm. Infants require 
flannel stockings, thick or thin, according to the season Care 
should be taken that the shoes produce no compression, and they 
should be exchanged for those of a larger size as often as is required 
by the growth of the feet. Deformity of the feet or toes, ingrow- 
ing toe-nail, and induration of the skin, can sometimes be traced 
back to tightness of a shoe in childhood. 



62 ACCIDENTS AND AILMENTS INCIDENTAL TO INFANTS. 

Physicians are so well aware of the importance of domiciliary 
cleanliness and ventilation, of the free admission into the nursery 
of solar light, and of the importance of out-door exercise as a 
means of invigorating the system and promoting healthy func- 
tional activity, that nothing need be stated in reference to these 
subjects in this connection. 



CHAPTEE IX. 

ACCIDENTS AND AILMENTS INCIDENTAL TO THE BIRTH OF 
THE INFANT, AND DETACHMENT OF THE CORD. 

Apncea (Asphyxia) Neonatorum. 

In the healthy infant, born under favorable circumstances, the 
two important functions of life, respiration and circulation, are 
established within the first minute. But it not infrequently hap- 
pens, in consequence of some unfavorable circumstance, that the 
heart and lungs fail to act, and the infant lies motionless as one 
dead. Sometimes in these cases an occasional pulsation of the 
heart can be detected when the fingers press under the left ribs, 
but there is no respiration. According to the nature of the cause, 
the surface is exsanguine or cyanotic and livid. 

Causes. — These are various. The fault may be partly in the 
infant ; it may be feeble in its development ; but the common causes 
are compression of the cord during birth, from breech presentation 
or otherwise, powerful, frequent, and long-continued uterine con- 
tractions, often induced by ergot, but sometimes occurring nor- 
mally, which compress the placenta, and consequently obstruct the 
foetal circulation ; detachment of the placenta before birth, and 
protracted labor, from pelvic malformation or otherwise, even when 
there is no unusual severity of the pains. 

Treatment. — Obviously the treatment must be prompt. Mucus 
should be removed from the mouth and fauces with the finger, 
and, except in those cases in which there has been placental hem- 
orrhage or ansemia from other causes, as exhibited by pallor of the 
surface, a few drops of blood should be allowed to run from the 
cut extremity of the cord. The flow induced aids in establishing 
the circulation, and, in the large proportion of cases in which there 
is congestion of internal organs, gives partial relief to it. Brisk 
rubbing of the body, slapping the buttocks, blowing in the face, 



APNCEA NEONATORUM. 63 

sprinkling water upon it, alternately transferring the body from a 
tub of hot to cold water may be tried in quick succession, and, if 
there are no signs of returning animation, no time should be lost 
in resorting to artificial respiration. 

The child should be placed on its side upon the edge of a table, 
with a blanket underneath it, and the head in such a position that 
the epiglottis falls forward ; a towel or napkin should be placed 
over its face, having a hole of sufficient size to blow through cor- 
responding with its mouth. The physician compressing firmly the 
epigastrium with his thumb, blows a full breath through the hole. 
A little of the air, notwithstanding the compression, enters the 
stomach, some may escape by the nostrils, and the rest enters the 
lungs. Immediately, the hand passing from the epigastrium to the 
thorax, compresses it gently though with sufficient force to produce 
expiration. This should be repeated six or eight times per minute. 
The action of the heart, previously slow, becomes quicker by the 
artificial respiration, and I am confident that I have been able to 
produce pulsations by this method when the heart had ceased to 
beat, and death, to all appearance, had occurred. Some recom- 
mend placing the infant on the right side, on account of the posi- 
tion of the valve between the auricles, but I think it is better to 
change it from one side to the other, in order to prevent conges- 
tions, which are so apt to occur when the circulation is imperfect. 
The circulation always commences sooner than respiration. The 
first respirations *are mere gasps, not more than one or two per 
minute in cases of decided asphyxia, but as they become more 
frequent they are also deeper. 

Artificial respiration should be continued ten or fifteen minutes 
in cases in which no* action of the heart can be detected by pressing 
the fingers under the ribs, when, if there are no signs of returning 
animation, the case is hopeless. If there is any pulsation, how- 
ever feeble, we should not cease in the attempt at resuscitation. 
Some prefer insufflation through a tube (as the segment of a catheter) 
introduced into the larynx, and pressure upon the thyroid carti- 
lage so as to close the pharynx, instead of upon the epigastrium. 
The principle of treatment is similar, but the mode which I have 
recommended above I have found successful beyond expectation. 
Thus, in one case in my practice in which pulsation in the um- 
bilical cord had ceased from ten to fifteen minutes before birth 
in consequence" of its prolapse, I employed artificial respiration 
nearly a quarter of an hour before there was any appreciable pul- 
sation, but by perseverance the circulatory and respiratory func- 



64 ACCIDENTS AND AILMENTS INCIDENTAL TO INFANTS. 

tions were fully re-established, and the child lived and was vigorous. 
When respiration commences insufflation may cease, but it is pro- 
per to aid the respiratory movements a little longer by compress- 
ing the thorax after each inspiration. Still, the physician may 
be disappointed in the result. In not a small proportion of cases 
the respiration continues gasping, and after a few hours, perhaps 
even a day, death ensues. I have made post-mortem examination 
of several infants who have died under such circumstances, chiefly 
in the Nursery and Child's Hospital, about six from recollection, 
and have found considerable uniformity in the appearance of the 
viscera. Only a small portion of the lungs, sometimes almost none 
at all , was found inflated, even when the cries had for a time been 
strong, and extravasated blood usually in considerable quantity 
lay upon the surface of the brain, evidently having escaped from 
the meningeal vessels, which were in a state of extreme congestion 
in consequence of the protracted or difficult birth. Meningeal 
apoplexy therefore seems to me the chief cause of the ill-success 
attending our efforts to save those who are so far resuscitated as to 
be able to breathe. 



Caput Succedaneum— Cephalaematoma. 

During the birth of the child, extravasation of blood not infre- 
quently occurs in the part of the scalp which presents. This results 
from the passive congestion, more or less intense according to the 
duration of labor and severity of the labor-pains, which occurs in 
the presenting part, whether scalp, arm, or breech. Caput succe- 
daneum is the term employed to designate the swelling thus caused. 
Its seat is the loose connective tissue of the scalp external to 
the pericranium. The tumor is soft, painless, and usually located 
upon the occiput. It consists partly of extravasated blood, but 
largely of serum which has transuded from the congested vessels 
before that degree of congestion was reached required to effect the 
transudation of the corpuscles. I have repeatedly had an oppor- 
tunity to examine this tumor in stillborn infants brought from the 
lying-in wards attached to the Nursery and Child's Hospital, and 
have found when it was slight that it consisted almost entirely 
of serum, but ordinarily when dissected it presented the appear- 
ance of a bruise, with a large proportion of serum, the blood and 
serum infiltrating the scalp to a greater or less distance beyond the 
appreciable limits of the tumor. Caput succedaneum requires no 
treatment. As it lies in the loose connective tissue of the scalp, 



CONJUNCTIVITIS NEONATORUM. 65 

its liquid permeates the open areolae in every direction, to be 
rapidly absorbed, while the tumor disappears. The subsidence of 
the swelling is usually complete within forty-eight hours. 

Occasionally blood is extra vasated under the pericranium, detach- 
ing it from the bone. This occurs in connection with caput succeda- 
neuni, and is observed when the latter declines. The tumor thus 
produced is designated cephalsematoma. It is situated upon the 
occipital or parietal bone, near the posterior fontanelle. Its base 
corresponding with the denuded bone is circular or oval, and it 
rarely crosses a suture. In rare instances two cephalsematomata 
occur, located upon the occipital and one parietal, or upon both 
parietal bones. The liquid, being surrounded by the firmly attached 
pericranium, does not escape in the surrounding tissues, as the caput 
succedaneum, and is therefore much more permanent. It flattens 
slowly by absorption, and does not disappear till after several weeks. 
At the age of six months a slight prominence can sometimes be 
detected, indicating the seat of the tumor. As the pericranium 
elevated by the blood does not lose its vitality, it soon begins to 
produce bone, so that after some days a ring of new bone can be 
detected by the finger surrounding the base of the tumor, and on 
the inside of the detached membrane a layer of bone is produced, 
thin at first and flexible, but gradually approximating the old bone, 
and becoming firmer as absorption occurs. 

Some time since, a specimen was presented by me to the ~N. Y. 
Pathological Society, showing this accident and the mode of cure. 
The child died about two months after birth, and the blood consti- 
tuting the tumor, which had been in great part absorbed, was com- 
pletely encased by the old bone below and the new thin formation 
above. The cavity at length becomes obliterated, and there only 
remains some thickening of that part of the cranium which corre- 
sponds with the location of the tumor. 



CHAPTER X. 

CONJUNCTIVITIS NEONATORUM. 

Inflammation of the conjunctiva in the new-born is not an un- 
usual disease. "We distinguish two forms of it, differing in gravity. 
It commences in the first week, and commonly about the third 
day. 

5 



66 CONJUNCTIVITIS NEONATORUM. 

Causes. — The causes of conjunctivitis neonatorum are not the 
same in all cases. The grave form, which has been designated 
purulent ophthalmia, has been known to occur during epidemics 
of puerperal fever, probably from the epidemic influence. Another 
cause, one which is easily understood, and which is universally 
recognized by the profession, is the introduction under the eyelids, 
during the birth of the child, of a particle of the vaginal secretion 
of the mother. The ordinary leucorrhceal, and still more gonor- 
rheal, secretion has this effect. Moreover, all accoucheurs meet 
occasional sporadic cases in cleanly and highly respectable families, 
occurring from some unknown cause, though perhaps in a certain 
proportion of these cases also a little of the leucorrhoeal discharge 
coming in contact with the conjunctiva has produced the inflam- 
mation. Certainly in private practice gonorrheal infection is in 
only a small proportion of cases the cause of purulent ophthalmia 
of the new-born. Some observers, as Prof. Gross, believe that the 
most frequent cause of purulent ophthalmia of the new-born is at- 
mospheric. 

The causes of the mild form are different also in different cases. 
Prominent among them are bad hygienic conditions, exposure of 
the eyes to a current of cold air, and the introduction of a little of 
the vernix caseosa or soap under the lids in the first washing. 

Symptoms. Severe Form. — In the beginning the palpebral con- 
junctiva is observed to be red, a little swollen, and its cutaneous 
surface presenting a faint reddish tinge. The light appears to be 
painful, and the child is fretful and sleeps but little ; but the eye 
itself presents its normal appearance. The progress of the disease, 
however, is rapid, and in twenty-four or thirty-six hours there is 
so much tumefaction that the upper lid extends over the lower, 
and it may be impossible to separate them sufficiently to obtain a 
view of the eye. The tumefaction is due to cedematous infiltra- 
tion. The conjunctiva, both palpebral and ocular, now presents a 
deep red hue, is thickened and swollen, and numerous fine granula- 
tions appear upon it: occasionally also flakes of very delicate pseudo- 
membrane can be observed in addition. There is an abundant pro- 
duction of pus of a creamy appearance, sometimes tinged with 
blood, which oozes out when the lids are separated. A critical 
period has now arrived, one which may involve the destruction of 
the cornea unless the case is promptly and judiciously treated. 
Indeed, the gravity of the disease relates chiefly to the state of the 
cornea, which up to the present time, notwithstanding the severity 
of the inflammation and the amount of surrounding infiltration, has 



CONJUNCTIVITIS NEONATOKUM. 67 

remained transparent and apparently unaffected. But within an- 
other twenty-four hours the cornea may lose its polish, and grayish, 
opaque spots of softening appear upon it. Soon perforation occurs, 
the aqueous humor escapes, and the iris falls forward, closing the 
aperture and preventing further loss of the liquids of the eye. 

I have observed destruction of the cornea and loss of sight chiefly, 
first, in cases of true gonorrhceal infection, in which there is the 
maximum amount of inflammation and tumefaction, extending 
even over the malar bone and supra-orbital ridge, with marked 
redness and elevation of temperature of the lids ; and, secondly, 
with a less degree of inflammation in those who were highly scro- 
fulous. In other cases I am of opinion that the cornea can ordi- 
narily be preserved with proper treatment, although there may be 
so much purulent discharge and oedema that it may be impossible 
to see it for several days. Occasionally the cornea, instead of slough- 
ing, becomes infiltrated to a greater or less extent, and ulcerates, 
but without perforation. As the patient recovers, cicatrization 
occurs. 

The inflammation soon begins to decline. The swelling, heat, 
and redness of the lids and conjunctiva, and the granulations, 
gradually disappear, and recovery is complete, except so far as the 
cornea may have been injured. 

Mild Form. — The inflammation is from the first of a mild grade, 
pertaining chiefly to the palpebral conjunctiva, with but a slight 
discharge of purulent matter, and with little swelling or increase 
of heat in the lids. Attention is directed to the complaint chiefly 
by the secretion which collects in the angles of the lids or upon 
their border. There may be slight intolerance of light, and ordi- 
narily minute granulations appear upon the inflamed mucous 
surface. This form of the disease may disappear within a few 
days, or it may be protracted. 

The conjunctivitis of the new-born is contagious, some forms of 
it highly so. It commences on one side, and, without precautions, 
commonly within a few days extends to the other. 

Treatment. — As soon as the inflammation occurs, the opposite 
sound eye should be covered with a compress, kept in place by 
strips of adhesive plaster. This eye should be examined, however, 
once or twice daily, in order to detect the commencement of in- 
flammation, and the bandage reapplied. 

The mild form of conjunctivitis requires very simple treatment. 
Frequently bathing the lids with lukewarm water, or milk and 
water, so as to remove the secretion from between the lids, suffices 



68 CONJUNCTIVITIS NEONATORUM. 

in a large proportion of cases. Among the poor the mothers ordi- 
narily bathe the lids with breast milk, and by this simple treat- 
ment effect a cure. If the inflammation should not abate soon by 
this treatment, a mild colly rium of one-eighth grain of nitrate of 
silver to one ounce of water should be applied between the lids and 
allowed to run under them. 

The severe form, or purulent ophthalmia, on the other hand, re- 
quires prompt and judicious management. There is scarcely a dis- 
ease in which delay is more disastrous. 

The frequent removing of the pus is very important, which is 
confined in large quantity underneath the closely compressed lids, 
and by its pressure and irritation increases greatly the danger of 
destruction of the cornea. Therefore the lids during the height of 
the inflammation should be pressed apart every hour, so as to 
allow the pus to escape, and the space between the lids be freed 
from pus by a camel-hair pencil. Occasionally warm water may be 
thrown under the lids by a small glass syringe, to wash away pus 
and any flakes of pseudo-membrane. Probably three or four drops 
of carbolic acid to each ounce of the water would be beneficial, 
from the known good effect of this agent on suppurating surfaces, 
but I have never employed it. 

Medicinal applications to the inflamed conjunctiva should, in 
my opinion, be simple and mild, but frequently applied. It is. 
known that Yon G-rafe recommended the application of nitrate of 
silver as a caustic ; but the operation is painful and difficult, for it 
requires eversion of the lids. I much prefer, in the treatment of 
purulent ophthalmia, the application of a weak solution of corro- 
sive sublimate every three hours between and under the lids, the 
pus, so far as practicable, having been first removed by the brush 
and syringe. I employ the following formula, and the result has, 
in my practice, been so favorable that I have not felt justified in 
trying another: — 

I£. Hyd. chlor. corros. gr. j ; 
Aquae rosarum ^ij ; 
Aquae |vj. Misce. 

Still, the beneficial result which I have observed in cases treated 
with this collyrium was no doubt partly due to the frequent re- 
moval of the pus, the importance of which cannot, in my opinion, 
be too highly estimated. In ordinary or mild cases of purulent 
ophthalmia, a light poultice of ground slippery elm, mixed with 
sugar of lead water, will be found useful ; but if there is great heat 
and swelling of the lids, a preferable application, while the inflam- 



DISEASES OF THE UMBILICUS. 69 

mation is intense, are pieces of a single thickness or two thick- 
nesses of muslin or linen an inch and a half square, taken from a 
cake of ice on which they lie, and renewed every two or three 
minutes when they begin to be warm. "When the inflammation 
has become less intense, and the danger of the destruction of the 
cornea is passed, the poultice or sugar of lead wash may be em- 
ployed instead. The decline of the inflammation is gradual, though 
generally pretty rapid. Occasionally granulations remain upon the 
lids. If they do not diminish and disappear when the purulent 
inflammation has ceased, I would not practise excision, as recom- 
mended by Vogel, but, having everted the lids, apply a solution of 
nitrate of silver, five or ten grains to the ounce, to the granulations 
each second day, and immediately wash away the solution by a 
camel-hair pencil with lukewarm water, and apply a little sweet 
oil before the lid is returned. If the granulations do not disap- 
pear with this treatment, they may be lightly touched with the 
smooth surface of a crystal of sulphate of copper, followed by the 
application of water and sweet oil. By this mode of treatment, 
employed from the commencement of the inflammation, a large 
proportion even of the severest cases recover with good vision. 



CHAPTER XI. 

DISEASES OF THE UMBILICUS. 

When properly managed, the cord desiccates and falls off between 
the third and ninth days. The nurse should not be allowed to oil it, 
which she will sometimes do unless forbidden, as this retards desic- 
cation. If the dressing of the cord is allowed to remain wet from 
the urine or otherwise, the cord does not desiccate, but decom- 
poses. This is not infrequent in poor, intemperate, and slovenly 
families. The decaying cord is apt to produce inflammation of the 
navel. Some southern physicians, prior to the late war, attributed 
the prevalence of trismus neonatorum among the slaves to the lesion 
of the navel produced by this cause, the trismus being then essen- 
tially traumatic. 

Inflammation of the Umbilical Vein and Arteries. 

When at birth the cord is ligated, if the child is in its normal 
state, clots form in the umbilical vessels from the navel inwards. 



70 DISEASES OF THE UMBILICUS. 

Atrophy of the vessels follows, and by the twenty-fifth day they 
are represented by small, firm, fibrous cords. Sometimes, though 
rarely, a true phlebitis or arteritis occurs in these vessels in the 
first days after birth, due either to the low vitality of the child 
and decomposition of the fibrinous plugs and gelatinous substance 
of the cord, or the entrance into the vessels of purulent or decaying 
matter from the fossa of the umbilicus. We are sometimes able, 
by pressing along the abdominal walls towards the umbilicus, to 
squeeze out a few drops of the decaying and purulent substance. 
The navel itself is usually inflamed at the same time. This is a 
very serious disease. Pus, with particles of disintegrated fibrin, is 
apt to pass along the vessels and enter the circulation, and, being- 
intercepted in distant parts, gives rise to embolismal inflammations. 
This seemed to be the cause of several subcutaneous inflammations, 
and points of embolismal pneumonitis in a new-born infant which 
I attended in 1868. The infant belonged to a family highly 
scrofulous and prone to scrofulous inflammations. Umbilical 
phlebitis and arteritis are said to occur most frequently in lying-in 
institutions during epidemics of puerperal fever. 

Treatment. — In the manner already indicated we should attempt 
gently to press out any purulent and decomposing substance from 
the vessels, and the infant should be placed with its abdomen de- 
pendent so far as it can be done without rendering it uncomfort- 
able, so as to aid in the escape of the liquids by gravity. The um- 
bilical fossa should be kept clean, and warm water containing a 
little carbolic acid may be dropped upon it several times daily. 
The abdomen should be covered with a soft and warm poultice. 

Inflammation and Ulceration of Umbilicus. 

Inflammation of the umbilicus sometimes occurs in the new- 
born about the time of the detachment of the cord, or soon after. 
It probably results from uncleanliness, or carelessness in the man- 
agement of the cord, by which irritating and decomposing sub- 
stances remain in the umbilical fossa. Sometimes decomposing 
particles from the cord are the probable irritant. This disease is 
also most apt to occur in cachectic infants, or those of scrofulous 
parentage, whose general condition renders them liable to inflam- 
mations. The umbilicus becomes red, slightly swollen, and moist 
by a secretion. Often the inflammation remains two or three days 
in this mild form, receiving no treatment except from the nurse, 
and disappearing by the use of the dusting powder which she 



UMBILICAL GRANULATIONS OR FUNGUS. 71 

employs. In other instances, the inflammation extends over a 
radius of an inch or even more, the walls of the umbilicus become 
swollen and infiltrated, and ulceration succeeds. The ulcer is cir- 
cular, occupying the site of the navel, and attended by a purulent 
discharge. The inflammation may nc*w gradually abate, and the 
ulcer heal with a cicatrix in place of the umbilicus. But in other 
instances, especially if there is a decided cachexia, the ulcer ex- 
tends in breadth and width, till finally, in the worst cases, the 
peritoneum becomes involved, and perforation or peritonitis occurs, 
with death. 

Under unfavorable hygienic circumstances, the blood of the 
infant being vitiated, the ulcer may become gangrenous, or the 
inflammation may terminate directly in mortification, without the 
formation of an ulcer. In either case the prognosis is unfavorable, 
if dark brown slough occupies the site of the umbilicus, and a 
sero-sanguineous discharge exudes from underneath. The common 
result is perforation, peritonitis, and death in from one to two 
weeks. 

Treatment. — Inflammation of the umbilicus, if at all severe, 
and especially when attended by any destruction of the tissues in- 
volved, rapidly reduces the strength. In such cases three or four 
drops of brandy should be administered every two hours in the 
breast milk. 

In the simple inflammation the navel should be bathed with 
lukewarm water three or four times daily, and the ointment of the 
oxide of zinc be constantly applied ; or if there is little or no dis- 
charge, the navel may be dusted with the powdered oxide of zinc. 
In case of ulceration the navel should be gently washed three or 
four times daily with lukewarm water, to which carbolic acid is 
added — fLye or six drops to the ounce ; and if there is much inflam- 
mation, a light poultice of pulverized slippery elm should be ap. 
plied in the interval, or if the inflammation is moderate, the balsam 
of Peru. If gangrene supervene, the parts should be frequently 
bathed with the carbolic acid water, and a cloth soaked with it be 
applied over it. The slough should be detached as soon as it is so 
far separated that its removal causes no hemorrhage, after which 
the treatment for ulceration is appropriate. 

Umbilical Granulations or Fungus. 

When the cord falls, granulations sometimes sprout out from the 
exposed raw surface, and complete cicatrization is impossible till 



72 UMBILICAL HEMORRHAGE. 

they are removed. They form a rounded mass of a pale reddish 
hue, at the centre of the umbilical fossa, bleeding when rubbed, 
and causing constant moisture of the umbilicus. The largest 
which I have seen had perhaps twice the size of a large pea, and 
they may be of any smaller size. 

Treatment. — By pressing upon the umbilical parietes the tumor 
rises from the fossa, so that a silk ligature can, be applied around 
its base, when the mass can be readily removed with the scissors. 
If the granulations are small, they may be removed by the scissors, 
without the ligature, and hemorrhage prevented by touching the 
surface with lunar caustic. 



CHAPTER XII. 

UMBILICAL HEMORRHAGE. 

The granulations which have been described above sometimes 
cause considerable hemorrhage when injured. The profuse and 
even fatal hemorrhage which occurs at birth, or soon after, from 
too loose a ligature of the umbilical cord, or from laceration or 
other injury, is so well known, and its cause so apparent, that it 
need only be alluded to in this connection. Bouchut details a case 
in which death occurred even before birth, from this form of 
hemorrhage. The child was attached to the placenta by a very 
short cord, which prevented delivery till it parted by the traction 
of the forceps ; but the bleeding from the umbilical vessels was so 
profuse, that the child was pallid and lifeless when born. 

There is another form of umbilical hemorrhage, cases of which 
have been from time to time observed for more than a century 
(one of the first on record was reported in the Gentleman'' s 31aga- 
zine, April, 1852, by Mr. Watts, a physician in Kent, England), 
but little was done to elucidate its nature till three American phy- 
sicians made it the subject of careful study, and the monographs 
which they have published upon it are the best which the litera- 
ture of the profession affords. Dr. Francis Minot read his paper, 
containing the statistics of 46 cases, before the Boston Society for 
Medical Improvement, in April, 1852. Prof. Stephen Smith pre- 
pared his paper, containing the statistics of 79 cases, for the New 
York Statistical Society, in 1855. It was published in the New 
York Journal of Medicine for that year. Dr. J. Poster Jenkins 



UMBILICAL HEMOEEHAGE. 73 

presented his monograph as a report to the United States Medical- 
Association in 1858, and it was published in- the Transactions of 
the Association for that year. This paper is very valuable on 
account of its statistics, as the writer succeeded in collecting the 
records of 178 cases, from medical journals, and gentlemen of the 
Association. These three papers contain nearly all that is known 
in reference to this disease. 

Sex, Age. — Females are less liable than males to this hemor- 
rhage. In Jenkins's cases, 34J per cent, were females, 65} males. 
The following table gives the age at which the hemorrhage com- 
menced in 99 cases: — 

Age. Nos. 

Under 1 day 5 

" 2 days .7 

" 3 " 6 

" 4 " 3 

5 to 7 " (inclusive) 32 

8 "10 " " . . . . . .25 

11 "15 " " 16 

16 "21 " " 4 

56 " . . . . 1 

99 

Ordinarily the hemorrhage commenced very soon after detach- 
ment of the cord, but in not a few the cord was still adherent. 

Causes. — The common proximate cause is feeble coagulability 
of the blood. In the normal state, when the cord is ligated, the 
fibrin of the blood, which now ceases to flow in the umbilical ves- 
sels, forms coagula so firm that, by the time the cord is detached, 
hemorrhage is impossible. But in the majority of those affected 
with this disease the clots are so soft and loose that they do not 
present any effectual barrier to the pressure of blood, which there- 
fore oozes through them or presses them away. This lack of co- 
agulability is easily demonstrated, for if a little blood, as it escapes, 
is caught in a vessel, it will be found to remain liquid a long time. 
This dyscrasia, or morbid state of the blood, which we therefore 
recognize as a chief cause of the hemorrhage, does not have the 
same origin in all cases. It is sometimes due to inherited syphilis. 
The infant affected with it may be plump, and appear well at birth, 
but, in most instances, when the hemorrhage is to occur, it is 
puny and cachectic, exhibiting also local manifestations of the dis- 
ease with which it is affected. Thus, in a case in my practice, the 
infant, puny, and apparently born before term, was observed to 
have several blebs of pemphigus on the first day, from some of 



74 UMBILICAL HEMORRHAGE. 

which blood soon began to ooze, bnt the fatal umbilical hemorrhage 
did not commence till after two weeks. 

In about one-fifth of the cases ecehymoses or petechia have been 
observed upon various parts of the surface, affording additional 
proof of the general blood disease. 

Jaundice is another cause of impoverishment of the blood in the 
new-born, and therefore of umbilical hemorrhage. The writers 
who have collected records of the hemorrhage, all remark the fre- 
quent occurrence of the icteric hue, both before and during the 
bleeding. It is not improbable that, in certain instances, the 
jaundice is hematogenous, arising from destruction of the red cor- 
puscles, and liberation of the hsematin, a not unusual result of 
a profound dyscrasia, whether syphilitic or originating in some 
other cause. But in other, and probably most instances, the jaun- 
dice proceeds from the liver, and is the cause of the change in the 
blood. Thus, in Rve of Jenkins's cases, there was occlusion of the 
hepatic or common bile-ducts, and jaundice, from the presence of 
biliary acids in the blood, causes diminution in the amount of fibrin 
and red corpuscles. In the ordinary form of icterus neonatorum, the 
cause of which is found in the relative fulness of the capillaries 
and minute bile-ducts in the acini of the liver, the coagulability of 
the blood must evidently be impaired in proportion to the degree 
and duration of the jaundice. 

Poor health of the mother, and impoverishment of her blood 
during gestation, whether from chronic disease, as tuberculosis, or 
anti-hygienic conditions, also causes impoverishment and dimin- 
ished coagulability of the blood of the child, and is therefore a 
cause of the hemorrhage. The excessive use of diluent drinks or 
alkalies by the mother is believed by some to have a similar effect. 

In certain cases the hemorrhage is due to an inherited hemorrhagic 
diathesis. In nine of Jenkins's cases the mothers were subject to 
monorrhagia, and liable to bleed freely after parturition, and from 
injuries; and seventeen other mothers had each lost more than one 
infant from umbilical hemorrhage. Probably in those cases in 
which the hemorrhage commenced before detachment of the cord, 
and external to the point of insertion, the hemorrhagic diathesis is 
the main cause of the flow. 

Although the cause of umbilical hemorrhage in the majority 
of cases is the vitiated state of the blood itself, high authorities, 
among others Sir James Y. Simpson, have met cases in which 
the hemorrhage was referable to the state of the vessels. In order 



UMBILICAL HEMORRHAGE. 75 

that the vessels be effectually closed by the fibrinous coagula, their 
walls should have their normal contractility, but this is in great 
part lost, by inflammation (arteritis or phlebitis) which sometimes 
occurs in these vessels, as we have already seen. Inflammation, 
whether of artery or vein, causes thickening and infiltration of its 
parietes, loss of tone on the part of the fibres of which they are 
composed, and therefore a patulous state of the vessel. Moreover, 
the inflammation is apt to be suppurative, and the presence of pus 
in the vessel obviously hinders the formation of a firm and effective 
coagulum. 

Symptoms. — Ordinarily umbilical hemorrhage occurs without any 
premonition, but sometimes it is preceded by jaundice. Jenkins 
ascertained that jaundice was a prodromic symptom in 41 out 
of 178 cases, and, with the icteric hue, constipation, clay-colored 
stools, deeply tinged urine, etc., were sometimes recorded. Rarely 
colicky pains and vomiting preceded the hemorrhage. The blood 
may be arterial or venous, or both. It oozes slowly or rapidly, 
rarely escaping in a jet, even when there is reason to believe that it 
is arterial. 

Prognosis. — This is unfavorable. Statistics show that five in 
every six perish. The prognosis is most unfavorable when jaun- 
dice or purpura is present. Those are most likely to recover who 
have a healthy parentage, no obvious dyscrasia, and in whom the 
hemorrhage occurs late and is not profuse. The average duration 
of the hemorrhage in 82 fatal cases in Jenkins's collection was 3J- 
days, the minimum being only three hours. After the arrest of 
the hemorrhage, death may occur from exhaustion or the dyscrasia. 

Treatment. — The treatment should be both constitutional and 
local. It is important, so far as time will permit, to treat the dys- 
crasia, and as the stools are apt to be constipated, a laxative is 
ordinarily indicated. A laxative is not only useful for its effect 
on the hepatic circulation, but as a derivative. Both Smith and 
Jenkins recommend calomel for this purpose. The modes of treat- 
ing the bleeding part have been various. Those most deserving 
of mention are the following: injecting a styptic into the open 
vessels, applying a styptic by compress or sponge to the navel, 
covering the navel with dry or wet plaster of Paris, constant pres- 
sure with the finger, which is tedious, but which maternal solici- 
tude willingly provides, and lastly the use of needles with ligature. 
All of these methods have been more or less successful in arresting 
the hemorrhage, but the last is most effectual, though painful. 



76 DIAGNOSIS OF INFANTILE DISEASES. 

Two needles should be passed through, the umbilicus at right angles, 
and a waxed thread wound around each in the form of figure 8. 
In four or five days the needles should be removed, and a poultice 
or simple dressing applied. 



CHAPTEE XIII. 

DIAGNOSIS OF INFANTILE DISEASES. 

General Observations. 

Diseases in early life differ in important particulars from those 
occurring in maturity. Some which are common in the former 
age are unknown or are rare in the latter, and those which occur 
equally at all ages often present peculiar symptoms and a peculiar 
clinical history in the young. Therefore physicians who are skil- 
ful in treating adults, may be unskilful in treating children. Ex- 
cellence as a physician of children can only be achieved by special 
and continued study of their ailments. 

Again, as regards the diseases of infancy, in which period there 
is a great amount of sickness and a large mortality, diagnosis must 
evidently be made from the objective symptoms ; from examining 
the features, attitude, utterances, the pulse, respiration, etc., and 
inspecting the surfaces, so far as they are accessible to view, and 
the eliminative products. "We lack for this age the important 
information which speech affords. Some general remarks, there- 
fore, in reference to the appearances and functions of the system in 
early life, and the changes which they undergo in various patho- 
logical states, seem requisite, in order to a clearer appreciation of 
the symptoms, and more ready diagnosis of individual diseases. 

Features, External Appearance of Head, Trunk, and Limbs in Disease. 

In the new-born, as soon as respiration and the new circulation 
are established, the cutaneous capillaries become distended with 
blood, and the skin presents a congested appearance. By the close 
of the first week this external hyperemia begins to abate, and is 
soon replaced by the normal capillary circulation. 

Icterus is common in the first and second week. Bouchut attri- 
butes it to mild hepatitis. A much more plausible view of its 



FEATURES, EXTERNAL APPEARANCE OF HEAD, ETC. 77 

causation, and probably the correct one, is that of Frerichs, who 
attributes it to the effect on the hepatic circulation of ligation of 
the umbilical cord. By ligation the current of blood through the 
umbilical vein to the liver ceases, the amount of blood in the 
hepatic capillaries, which connect with the branches of the vein, 
diminishes, and then, according to Frerichs, diversion occurs of a 
part of the bile from the hepatic cells into the capillaries, while 
the rest flows in the normal manner in the bile-ducts. The degree 
of jaundice is proportionate to the amount of bile which enters 
the circulation. Icterus neonatorum is not a disease of importance. 
It subsides without medicine in the course of one or two weeks, 
when the circulation through the liver becomes equalized and 
regular. 

The surface, or portions of the surface, of the new-born often pre- 
sent for a few hours a livid color due to the mode of delivery. 
Protracted lividity occurs from atelectasis or malformation in the 
heart or great vessels ; lividity induced by exertion or excitement 
while the respiration is normal, indicates malformation of the heart 
or vessels ; temporary lividity sometimes occurs in severe acute 
diseases, especially those of the respiratory organs ; lividity, whether 
temporary or permanent, is a sign of imperfect decarbonization of 
the blood. 

The cheeks of children are congested in febrile and inflamma- 
tory diseases, except in cachectic or prostrated state of system. 
Transient circumscribed congestion of the face, ears, or forehead 
constitutes a reliable sign of cerebral disease. Strabismus occurring 
in connection with febrile reaction, oscillation of iris, inequality of 
pupils, and drooping of upper eyelids, also denote cerebral disease. 
The pupils are contracted during sleep; evenly dilated in death. 

Dilation of the alee nasi during inspiration, with contraction of 
the eyebrows and a countenance indicative of suffering, attends 
severe irrflammation of the respiratory organs. Absence of tears 
during the act of crying shows a severe and probably fatal form of 
disease in infants over the age of four'months. 

Eapid wasting of the features, causing deep suborbital depres- 
sions, prominence and pointedness of the cheek-bones and chin, and 
hollowness of the cheeks, is a sign of a severe diarrhoeal affection ; 
the most striking examples of this sudden collapse of features are 
afforded by patients affected with cholera infantum. In severe cases 
of this disease, the physiognomy, from a state of fulness and health, 
presents in a few hours such a wasted and senile appearance that 
the friends with difficulty recognize the features with which they 



78 DIAGNOSIS OF INFANTILE DISEASES. 

are familiar. Muscular tonicity is also greatly impaired in this 
disease, that of the orbicular muscles of the lips and eyelids to 
such an extent that the mouth is open and eyeballs exposed during 
sleep. Great emaciation occurring gradually, is a symptom of sub- 
acute or chronic disease of a grave character, often of tuberculosis 
or chronic entero-colitis. 

Strabismus sometimes occurs in children who have no serious 
disease. It is then due to simple paralysis of one or more of the 
motor muscles of the eye. But when supervening upon other 
symptoms of a neuropathic character, it is a grave symptom, indi- 
cating organic disease of the encephalon, as effusion, meningitis, etc. 
A permanently downward direction of the axes of the eyes, with 
smallness of the face and great expansion of the cranium, is a sign 
of congenital hydrocephalus. The scalp in this disease is tense, 
bald, or sparingly covered with hair, the fontanelles and sutures 
open and enlarged, and the cranial bones yielding to pressure. 
Great expansion of the cranium above the ears, while the frontal 
portion is not enlarged, or but slightly, denotes hypertrophy of the 
brain. 

The appearance of the general cutaneous surface possesses much 
greater diagnostic value in the diseases of infancy and childhood 
than in those of adult life. The eruptive fevers so common in the 
young, and comparatively rare in the adult, reveal themselves to us 
in great part by the changes which they cause in the appearance of 
the integument. The peculiar color of the skin in constitutional 
syphilis, hereafter to be described, and which is more marked in 
infancy and early childhood than at any other age, is a diagnostic 
sign of great value in obscure cases. In the infant the cold stage 
of intermittent fever is manifested, not by muscular tremors, but 
by lividity, pallor, and the goose-skin appearance of the surface. 

Bulbous enlargement of the fingers and incurvation of the nails 
are signs of cyanosis, and therefore of malformation at the centre 
of the circulatory apparatus, or of tuberculosis, or chronic pulmo- 
nary disease attended by malnutrition. Enlargement of the spongy 
portions of bones, causing prominences, softness, and bending of the 
bones, and consequent deformity of the limbs, patency of the fonta- 
nelles, a large and square shape of the head from calcareous deposit 
external to the cranium, are among the signs of rachitis. 

In early infancy the glands of the skin and mucous surfaces, or 
which connect by their orifices with these surfaces, are slightly 
developed. Therefore sensible perspiration and lachrymation are 
rare under the age of three months. A thick Meibomian secretion 



ATTITUDE — MOVEMENTS — THE VOICE. 79 

of a puriform appearance collecting between the eyelids, is an un- 
favorable prognostic sign ; it indicates a state of great depression ; 
it is observed most frequently in cerebral and intestinal affections 
a little before death. Passive congestion of the vessels of the 
conjunctiva sometimes occurs under the same circumstances, due 
to feebleness of the heart's action, and imperfect capillary circula- 
tion. It indicates the near approach of death. 

Attitude— Movements — The Voice. 

A sharp, piercing cry, head firmly retracted, flexure of the limbs 
with a degree of rigidity, adduction of the great toe, clonic or tonic 
spasm of the muscles, irregular movements of one or more limbs, 
with consciousness impaired, or with mental hallucinations, are 
symptoms of grave disease of the cerebro-spinal system. Irregular 
muscular movements partly controlled by the will, and occurring 
during full consciousness, are symptoms of chorea, a disease nearly 
always ending favorably in children, though incurable in the adult. 
Contraction of the eyebrows, turning of the eyes and face from 
light, avoidance of noises, as if painful, are signs of headache. 
Frequent carrying of the hand to the ear, and pressing with the ear 
against the breast of the mother or nurse, are symptoms of otalgia. 
Frequent carrying of the fingers to the mouth, in connection with 
fretfulness or other symptoms of suffering, indicates stomatitis, 
gengivitis whether from difficult dentition or other causes, painful 
pharyngitis, or some obstructive disease of the larynx. Frequent 
rubbing or pressing the nose may be due to intestinal worms or 
intestinal irritation from other causes. It may be due to coryza 
or headache. Frequent forcible rubbing or striking the nose should 
lead to a careful examination and perhaps guarded prognosis. It 
often indicates grave cerebral disease, and may be a precursor of 
convulsions. 

In severe obstructive disease of the larynx, the child is restless, 
moving from side to side. In most inflammations of the respira- 
tory organs, a semi-erect position gives most relief. The voice in 
severe laryngitis is often hoarse or indistinct, and usually so in the 
pseudo-membranous form; in pleuritis or pneumonitis it is re- 
strained and abrupt, since the movements of the wails of the chest 
give pain. 

The voice in severe diseases of the abdominal organs is feeble 
and plaintive. It is sometimes short and restrained in acute dys- 
pepsia, in peritonitis, and in cases of great abdominal distension. 



80 DIAGNOSIS OF INFANTILE DISEASES. 

The horizontal position gives most relief in abdominal diseases. 
In case of abdominal pain the patient often presses his hand upon 
the abdomen and flexes his thigh over it. Perfect quietude, with 
features sunken, and unchanged by smile or crying, is a symptom 
of severe and exhausting diarrhceal affections. 

Respiratory System. 

The respiration of the infant under the age of six months is very 
irregular, and it is more irregular the nearer the time to birth. If 
the new-born infant is closely observed, it will be seen to sigh often ; 
it breathes pretty uniformly and regularly for a moment, and then, 
without appreciable cause, the respiration is intermitted ; it holds 
its breath when it smiles or moves its head, or even its limbs; it is 
very subject to hiccup ; this is more common the first week of life 
than at any other age. So much is the breathing of the young 
infant disturbed by these causes, that the number of respirations 
ordinarily varies in consecutive minutes. In order, therefore, to 
determine with accuracy the frequency of the normal respiration 
for this time of life, it is necessary to take the average of several 
observations. 

At birth, while the function of the heart has for months been 
regularly performed, the lungs are still quiescent. The one organ 
has been active during the greater part of foetal development, the 
other is yet untried. Hereafter, the new order of things, so inti- 
mate is the relation between the heart and lungs, that the proper 
performance of the function of one is essential to that of the other. 
Therefore the commencement of respiration and the return of cir- 
culation, which is modified and temporarily arrested at birth, are 
nearly simultaneous. Respiration commences in the first half- 
minute of independent existence ; often, indeed, attempts to inspire 
occur before the delivery is completed. The exceptions to this 
early establishment of respiration are, after tedious or unnatural 
births. The return of circulation is a moment later. 

Respiration in Health. — As the air-cells at birth are closed, 
the establishment of respiration is difficult. The air at first pene- 
trates a few pulmonary cells, but gradually more and more are 
inflated through the forcible inspirations which the crying of the 
infant produces, till after a variable time respiration becomes easy 
and complete. If the cry is feeble, and especially if with this 
feebleness there is considerable congestion of the brain, the result 



RESPIRATORY SYSTEM. 



81 



of tedious birth, the full establishment of respiration is in a cor- 
responding degree gradual and slow. 

The frequency of the respiration in health should be ascertained, 
in order to determine whether, in a given case, it is abnormally 
accelerated. The following table embodies the result of observa- 
tions which I have made, in order to determine the normal fre- 
quency of respiration in the first year of life. 

Normal Infantile Respiration {number per minute). 









AGE. 










From first 


From close 


From close of 


Close of 


Close of 






half hour to 


of first week 


first month 


third to close 


sixth month 






close of first 


to close of 


to close of 


of sixth 


to close of 




First 
half 
hour. 


week. 


first month. 


third. 


month. 


first year. 




< 


p. 

< 


cd 
M 

< 


<o 
<s> 
to 
< 


a 

< 


p. 

<0 
an 
< 


a> 

< 


c 

CD 
CO 

< 


6 
M 

a 

< 


p< 

CD 

CO 

<! 


Number of observations 


29 


28 


14 


13 


13 


16 


10 


25 


7 


19 


6 


Extreme number of respi- ) 
rations per minute ( 

Mean number of respira- > 
tions per minute $ 


25-104 


32-64 


40-64 


40-96 


28-60 


32-68 


2S-52 


36-88 


24-40 


28-64 


24-36 


48.5 


52 


52 


59 


45 


51 


39 


54 


33 


41 


29 



As the child advances from the age of one year, the number of 
respirations per minute gradually diminishes; but through the 
whole period of childhood it remains greater than in the adult. 
At the age of five years, when the child is quiet, but awake, it is 
about 27 ; at the age of ten years, about 22. 

Bespiration in Disease. — In cerebral diseases the respiration is 
apt to be slow, and if somnolence occur, intermittent, and accom- 
panied by sighing. In young infants, in the drowsiness which 
supervenes when the blood is imperfectly decarbonized, during 
severe attacks of capillary bronchitis, or broncho-pneumonia, respi- 
ration is apt to be intermittent. 

In inflammatory diseases of the larynx and trachea, respiration 
is but slightly accelerated, and, if there is no obstruction, its 
rhythm is normal; if there is obstructive disease, its rhythm is 
altered ; the inspiratory act is lengthened. In bronchitis, respira- 
tion is accelerated in proportion to the degree of extension down- 
ward of the inflammation. It is in no disease more accelerated 
than in severe capillary bronchitis. 

In pleuritis and pneumonitis, the respiration is accelerated in 
proportion to the extent and acuteness of the inflammation. In- 
spiration ending abruptly, and succeeded by an expiratory moan, 



82 DIAGNOSIS OF INFANTILE DISEASES. 

is a symptom of both pleuritis and pneumonitis in their acute 
stages. In certain cases of irritative or inflammatory disease of the 
abdominal organs, respiration presents a similar character; it is 
modified in this manner in consequence of the pain experienced in 
movements of the diaphragm. Ordinarily, however, in abdominal 
diseases, respiration is nearly natural. 

The cough is an important diagnostic symptom. It is loud and 
sonorous in spasmodic croup ; hoarse or harsh in true croup ; clear 
or distinct in bronchitis ; suppressed and painful in the early stages 
of pneumonitis and pleuritis ; convulsive, and with more inspira- 
tions than expirations, in pertussis. A cough is one of the first 
and most constant symptoms of measles ; it is due to coexisting 
bronchitis. Typhoid and remittent fevers, difficult dentition, in- 
testinal worms, irritating ingesta, and severe burns, sometimes 
give rise to a cough, which is nearly dry and painless. Occurring 
in such diseases, it is sometimes dependent on more or less bron- 
chitis, to which the primary disease has given rise. 

Circulatory System. 

In all ages and countries the pulse has been considered an im- 
portant symptom both in diagnosis and prognosis. It aids the 
practitioner in determining, approximatively, not only the character, 
but gravity of diseases. It is somewhat remarkable, from the im- 
portance which is attached to the pulse in medical practice, that 
its natural frequency and its character in infancy are not more 
accurately known. It is true that eminent observers, as Trousseau 
and Valleix, have published statistics relating to the infantile pulse 
in health, but these statistics disagree, and therefore do not afford 
a reliable standard with which to compare the pulse in disease. 
Moreover, some published statistics of the pulse possess but little 
value, from the small number of observations ; some from the fact 
that records of the infantile pulse are grouped with those of older 
children ; and others because the state of the infant, as regards its 
activity or emotions, is not mentioned. 

Pulse in Health. — It is not easy to collect statistics of the 
healthy pulse for the period of infancy, which are entirely free from 
error, since there are often slight derangements of the system in 
the infant, which are not manifested by any marked symptoms, 
but which produce acceleration of the pulse. In collecting the 



CIKCITLATORY SYSTEM. 



83 



following statistics, it was my endeavor to avoid sources of error 
so far as possible. 

In ordinary cases the movements of the heart begin about one- 
eighth of a minute after birth. They are at first slow, the ven- 
tricular contractions not numbering more than eight or ten by the 
close of the first quarter minute. In the second quarter the cries 
are vigorous, and the pulse now is rapidly accelerated, rising 
commonly above 120, and sometimes above 160 beats per minute. 
In fifty-seven observations of the pulse in healthy infants during 
the first half hour of life, after the first quarter of a minute, I 
found that the extremes, with one exception, were 104 and 164 — 
average 139. 







Table of Infantile Pulse in Health, 










AGE. 




First week. 


From close of 

first week to 

close of first 

month. 


From close of 
first month to 
close of third. 


From close of 
third month to 
close of sixth. 


From close of 

sixth month to 

close of first 

year. 




Awake. 
Quiet ; 
moving 
slightly; 
nursing. 


Asleep. 


Awake. 
Quiet; 
moving 
slightly; 
nursing. 


Asleep. 


Awake. 
Quiet; 
moving 
slightly; 
nursing. 


Asleep. 


Awake. 
Quiet; 
moving 
slightly; 
nursing. 


Asleep. 


Awake. 
Quiet; 
moving 
slightly; 
nursing. 


Asleep. 


No. of obser- ) 
vation $ 

Extremes 


22 

104-152 

126 


16 

108-140 

122 


10 

124-160 

139 


10 

104-144 

118 


15 

112-148 

132 


17 

104-132 

118 


25 

112-146 

129 


6 
104-116 

108 


20 
112-144 

127 


3 

109 





" M. Ledeberder," says Bouchut, " could only count the pulse in 
the first minute of life in six children, and he has observed from 
72 to 94 pulsations." Valleix estimates the pulse, between the 
ages of two and twenty-one days, at 87. Trousseau states that the 
pulse, in the first week of life, varies from 78 to 150; and Dr. 
G-orham's observations are somewhat similar to Trousseau's. My 
observations, as seen from the above table, do not correspond with 
the assertions of Ledeberder and Valleix. Indeed, if there were 
no conflicting testimony, there would still be a strong presumption 
that these authors are in error, for we would not suppose that the 
pulse of the infant, in whom there is greater functional activity, 
both muscular and visceral, would fall so much below that of the 
foetus. It is probable, from the expression " could only count the 
pulse ... in six children," that Ledeberder and perhaps Val- 
leix counted the pulse at the wrist, which, with exceptional cases, 
is very difficult and often impossible in the first week of life, and 



84 



DIAGNOSIS OF INFANTILE DISEASES, 



that they missed some of the beats, or, not unlikely, sometimes 
counted their own pulse. Immediately after birth there is so little 
force of the ventricular systole, and the extreme arteries, there- 
fore, of the system pulsate so feebly, that neither in the limbs nor 
at the anterior fontanelle can the frequency of the pulse be readily 
ascertained. It can be readily and accurately ascertained only by 
auscultation, or by placing the hand on the precordial region, or 
directly after birth by the pulsations in the umbilical cord. 

The average pulse of the healthy infant in the first and second 
months is, according to Trousseau, 137 per minute, 128 from the 
third to the sixth month, and 120 from the sixth to the twelfth 
month. It is seen that his observations agree closely with mine, 
as regards infants who are quiet but awake. One point of interest, 
established by the above statistics, is the great diminution in the 
frequency of the pulse in sleep. 

Pulse during or after Active Movements or Great Mental Excitement. 







Close of first 


Close of first 


Close of third 


Close of sixth 




First week. 


week to close of 


to close of third 


to close of sixth 


month to close 






first month. 


month. 


month. 


of first year. 




140 


162 


176 


132 


132 




160 


156 


152 


148 


144 




140 


140 


158 


148 


152 




. 152 


152 


144 


144 


152 








152 


156 


198 








180 


156 


160 


Extremes 


140-160 


146-162 


144-180 


132-156 


132-198 


Mean 


148 


152 


160 


147 


156 







It is seen, by the above table, that by active exercise or great 
mental excitement the pulse may become as rapid as in grave 
diseases. There is greater acceleration of pulse from the emotions 
and from exercise in feeble than in robust children. Obviously, in 
order to determine to what extent the pulse is accelerated in dis- 
ease, it is necessary that it should be counted during a state of 
quietude. As the age increases, it is less and less influenced by 
the emotions and physical exertion ; still, during the whole period 
of childhood, such influences do have more or less effect on its 
frequency. 



Pulse in Disease. — Febrile and inflammatory diseases produce 
greater acceleration of pulse in early life than in maturity. Dis- 



ANIMAL HEAT. 85 

eases, or derangements of system, particularly those of the diges- 
tive organs, which do not materially affect the pulse in the adult, 
often cause acceleration of it in children. The febrile pulse of 
early life usually has exacerbations in its frequency. These com- 
monly occur in the latter part of the day. Distinct and more or 
less regular febrile exacerbations and remissions are common in 
several diseases of early life, some of which are serious, while 
others involve little danger. Among these diseases may be men- 
tioned difficult dentition, intestinal worms, incipient meningitis, 
and constipation. An intermittent and irregular pulse is common 
in fully developed meningitis and certain other severe organic dis- 
eases of the encephalon. It may be due also to disease of the heart, 
and it also occurs in some children from temporary disturbance of 
the digestive function. The pulse is slow in compression of the 
brain, and also in sclerema of the new-born. 



Animal Heat. 

The internal temperature of the body in a state of health is 
uniform. In 33 infants under the age of seven days, M. Roger 
found the average temperature 98°. 6 Fahr., while in 25 from four 
months to fourteen years old it was 99°. The external tempera- 
ture alone varies in a state of health, according to the temperature 
of the atmosphere. 

Elevation of temperature above the normal standard is a sign 
of inflammatory and febrile affections. The increase of heat 
varies according to the character of the disease and its type. In 
favorable cases of inflammation and in simple fevers it is not 
ordinarily more than two or three degrees. The greater the severity 
and malignancy of inflammatory and febrile diseases, the greater 
the elevation. An elevation of more than six degrees indicates a 
form of disease which is likely to prove fatal. It is rare that the 
temperature, even in fatal cases, rises above 107°. In measles the 
temperature in the eruptive stage is from 101° to 103° ; in scarla- 
tina from 102° to 104°, if no complication exist. 

Seduction of the internal temperature is an unfavorable prog- 
nostic sign ; it is observed, a few hours before death, in infants 
who are greatly reduced by certain chronic diseases, as entero- 
colitis. In these cases the tongue and even sometimes the breath 
communicate to the finger or hand a sensation of coldness. 

The importance of thermometric observations, as an aid to the 
diagnosis of children's diseases, is within a few years more fully 



86 DIAGNOSIS OF INFANTILE DISEASES. 

recognized by the profession. Two diseases which, in their com- 
mencement, present very similar symptoms, often vary as regards 
the temperature. Thus, meningitis presenting in its first stages 
symptoms very similar to those of typhoid fever, has a lower tem- 
perature till an advanced period, when the amount of heat increases. 

Digestive System. 

Inspection of the buccal and faucial surfaces discloses some of 
the most frequent local diseases of infancy, as the various forms 
of stomatitis, and others which, though not frequent, involve great 
danger, as gangrene of the mouth, diphtheria, and retropharyn- 
geal abscess. Inspection of the tongue aids in determining in 
many cases whether the disease is pursuing a favorable course, or 
has become asthenic, and is exhausting the vital powers. 

Febrile movements, even when slight, give rise to coating of the 
tongue, and intumescence and distinctness of its follicles. The 
eruptive fevers are attended by changes upon the buccal and 
faucial surfaces which possess diagnostic and prognostic value. 
Hyperemia of these surfaces appears early in rubeola and scarlatina, 
prior to those phenomena which are justly regarded as pathogno- 
monic. It is therefore often an important sign in the initial period 
of those diseases when the diagnosis is obscure. The appearance of 
the fauces in diphtheria and croup, indicating not only the nature 
of the disease, but its gravity, need only be referred to in this con- 
nection. 

Inspection of the buccal and faucial surfaces sometimes enables 
us to form a probable opinion in reference to the nature of diseases 
which are seated in other parts. In the infant protracted stomatitis 
is a common accompaniment of chronic diarrhoea, and it indicates 
its inflammatory nature. 

Vomiting is more frequent in infancy than in childhood, and in 
either period than in adult life. It is common in cerebral affec- 
tions, and is one of the first symptoms of scarlet fever, and it is 
not uncommon, though less frequent, in the commencement of the 
other essential fevers and of acute inflammations. It is a symp- 
tom of indigestion, entero-colitis, cholera infantum, and intussus- 
ception ; it is common, also, after the paroxysmal cough of pertussis, 
and not infrequent in the bronchial inflammations of young infants ; 
in both which diseases it is excited by the muco-purulent matter 
upon the faucial surface. 

Intestinal gas is in part secreted or exhaled from the mucous 



DIGESTIVE SYSTEM, 



87 



membrane, as the experiments of Hunter and others have shown, 
and it is in part the product of chemical changes in the food. A 
certain amount of gas in the intestines is normal ; it subserves a 
useful purpose. An abnormal amount of it is common in various 
diseases, as indigestion, chronic entero-colitis, peritonitis, typhoid 
fever. It is a frequent cause of gastralgia and enteralgia in the 
infant. In scrofulous or feeble infants, with impaired muscular 
tonicity and faulty digestion, the abdomen is often habitually 
more or less distended with gas, which does not, under such circum- 
stances, give rise to pain or other local symptoms ; it has signifi- 
cance as showing the general condition of the child. 

In the rachitic, whose thorax is compressed and liver often en- 
larged, while the vertebral column is shortened, the abdomen is 
commonly protuberant. In feeble chil- 
dren, not decidedly rachitic, whose lungs 
are seldom fully inflated, and whose chests 
are consequently depressed, the abdomen 
is also prominent. The accompanying 
wood-cut represents one of these cases, 
presented for treatment at the out-door 
department at Bellevue. 

In feeble children who have suffered 
from repeated and protracted attacks of 
bronchitis, and whose chest-walls are con- 
sequently depressed, a similar abdominal 
prominence occurs. 

Retraction of the abdominal walls is 
common in meningitis, and in many ex- 
hausting diseases. Tenesmus is a symp- 
tom of intussusception in the infant, and 
of colitis in children. 

Much light is thrown on the character of intestinal diseases by 
the appearance of the stools. Muco-sanguineous stools, accompanied 
by fever, are a sign of colitis. Stools containing unmixed blood, 
and not accompanied by fever, may result from a rectal polypus 
and from purpura hemorrhagica. Scanty evacuations of blood 
with obstinate constipation, are a symptom of intussusception in 
infants. 

The alvine discharges of infants often present a green color ; 
sometimes they have the normal yellow hue when passed from the 
bowels, but become green on exposure to the air, or from reaction 
of the urine. By the microscope the green coloring matter is 




88 DIAGNOSIS OF INFANTILE DISEASES. 

seen to occur in small irregular masses. This green substance has 
been supposed to be bile. I have satisfied myself that, as met in 
the stools of the infant, it is commonly produced by the action of 
the intestinal secretions on the contents of the intestines ; perhaps 
the action is upon the bile which is mingled with the contents. 
I have often noticed the contents in and above the jejunum yellow, 
while in and below the ileum the color was green. 

The green hue may occur from very different causes. It may 
be due to overfeeding, to the action of cold, to irritating ingesta, 
to inflammation, etc. ; it may be transient, subsiding within a day 
or two, or it may continue several days. All infants, at times, 
have green evacuations, even when they appear in good health. 

The alvine discharges of infants, in a large proportion of cases 
of diarrhceal affections, give an acid reaction with litmus paper. 
This acid, if in considerable quantity, is irritating, increasing the 
peristaltic movements of the intestines, and the functional activity 
of the intestinal follicles, causing erythema of the skin around 
the anus, and reacting upon and intensifying the intestinal dis- 
ease. Hence the indication for the use of antacids in the diar- 
rhceal affections of infancy. 

The presence of intestinal worms, and the species, may be ascer- 
tained by microscopic examination of the stools of the child who 
is affected with these entozoa. The stools contain ova, which dif- 
fer in size and shape according to the species of worm. 

Nervous System. 

Pain. — This symptom affords important aid to the physician in 
determining the seat and nature of the diseases of children. Pain 
in the head may occur in them from coryza involving the frontal 
sinuses, febrile movement in the commencement of an essential 
fever, or of inflammation of one of the organs of the trunk. 
Produced by such a cause, it abates in two or three days. If it is 
protracted, whether constant or intermittent, it is almost never 
neuralgic, as it so often is in the adult, but it is due to organic 
disease of the brain or meninges. Complaint, therefore, of head- 
ache in a child, without any apparent general cause, or local cause 
external to the cranium, should awaken solicitude, and, if the 
headache is protracted, the prognosis should be doubtful, even if 
other symptoms are absent. 

Grave thoracic or abdominal inflammations in the adult are 
almost always attended by a corresponding amount of pain and 



NERVOUS SYSTEM. 89 

tenderness ; but in children these symptoms are often absent, or, 
when present, are often not commensurate with the amount of dis- 
ease. Thus, entero-colitis of nursing infants is, in a large propor- 
tion of instances, almost free from these symptoms, and the same 
may be said of many cases of the form of pneumonia, which is 
common in young children, namely, tl^at produced by extension of 
inflammation from the bronchial tubes and that from hypostasis. 

Pain in the chest or abdomen, occasional or constant, continuing 
for weeks or months, unattended by symptoms of thoracic or abdo- 
minal disease, indicates caries of the vertebrae. Its most common 
seat is the epigastric,. umbilical, or hypochondriac region. It is a 
neuralgia due to irritation of the sensitive root of one or more of 
the spinal nerves. It is a very important symptom to the diagnos- 
tician, showing the nature of the disease, which in its incipiency 
is so obscure. Pain in the leg, especially the inside of the knee, 
is of a similar character, indicating disease of the hip-joint. 

Children with certain acute febrile and inflammatory diseases 
sometimes have hyperesthesia of portions of the surface, especially 
marked upon the anterior aspect of the trunk. The physician might 
be misled into the belief that the tenderness indicated the seat 
of the disease ; but the pain of hyperesthesia can be determined 
by the fact that it is so extensive, is less on firm than light pres- 
sure, and is especially observed upon the inner surface of the thighs. 
The symptoms pertaining to the nervous system present in the 
various diseases treated of in this book will be fully described in 
connection with those diseases, and, therefore, need not detain us 
in this connection. 



PART II. 

CONSTITUTIONAL DISEASES. 



SECTION I. 

DIATHETIC DISEASES. 
CHAPTER I. 



RACHITIS. 

Rachitis, or rickets, is a disease of the general nutritive process ; 
but the structural changes which attend and characterize it are 
most conspicuous in the bones. 

Age. — Rachitis commences in most instances between the ages 
of six months and two years. iSTow and then we meet cases of its 
earlier as well as later commencement, and skeletons are preserved 
in museums, which, it is claimed, establish the fact that in rare 
instances rachitis is congenital. Virchow alludes 
to such a specimen in the Wurzburg Museum, and 
Ritter von Rittershain describes another in the 
Museum of the Franz Joseph Hospital in Prague. 
In the "Wood Museum of Belle vue Hospital is a 
similar skeleton presented by myself. The infant 
in this case died a few hours after birth, of atelec- 
tasis, apparently produced by the contracted state 
of the thoracic walls. This skeleton exhibits most 
of the curvatures and deformities which occur in 
rachitis, but as the nodosities of the articulations 
are wanting, and the bones, apart from their gene- 
ral shape, appear normal, competent pathologists 
of this city have expressed the opinion that the 
malformation in this case was probably the result 
of some unknown error of nutrition rather than 
rachitis. The annexed representation will allow 
the reader to judge for himself. The parents are 




92 EACHITIS. 

hard-working English people, having children who appear scro- 
fulous, but not rachitic. 

Enlargement of the costo-chondral articulations, known as the 
" rachitic rosary," which is one of the earliest and most reliable 
signs of rachitis, has been observed, though rarely, in infants of 
two or three months. It should not, however, be regarded as a 
sign of rachitis unless the enlargement is so great that it can be 
readily appreciated by examination through the integument or by 
sight, for in young children, with the bones in the process of 
normal development, these points always have a greater diameter 
than that of the ribs. After the age of two years the number of 
those affected with rachitis gradually becomes less as we pass to- 
wards manhood. 

Published statistics relating to the commencement of rachitis 
have been derived chiefly from European hospitals. Of 521 cases 
observed by Bitter von Bittershain, 266 were under the age of 
twelve months, and 91 under six months. Of Hillier's cases, 7 
were six months old or under, 27 from six to twelve months, 40 
from twelve to twenty-four months, 40 from two years to four 
years, and 3 over the age of four years. As rachitis so often com- 
mences insidiously, these statistics must be considered only ap- 
proximately correct, especially as regards those cases which are 
supposed to have had an unusually late commencement. 

Is rachitis ever developed in the adult? Osteo-malacia, or 
mollities ossium, a rare disease of adults, occurring with few ex- 
ceptions in' women after childbirth, resembles rachitis, since it is 
attended with softening of the bones from the absorption of their 
calcareous element. Trousseau, and following him, Bouchut, believe 
in their essential identity, regarding their differences as due to the 
difference in age, and especially to the fact that in osteo-malacia 
the bone has attained its growth, whereas in rachitis it is still 
growing. Moreover, as arguments in favor of their close relation- 
ship, rachitis and osteo-malacia are found to require very similar 
treatment, and women after childbirth resemble children as regards 
aptitude for disease. That the two pathological processes are not, 
however, exactly identical, appears from the researches of Virchow. 
In osteo-malacia the bones become soft and flexible from absorption 
of the lime salts, whereas in rachitis there does not appear to be 
any more loss of the lime than occurs in the normal growth of 
bone, but its further deposit is arrested. In the normal develop- 
ment of bone the deposit of lime is in excess of the absorption, 
but in rachitis, the absorption continuing, with an arrest of depo- 



EACHITIS. 93 

sition, it is easy to see how the bone soon becomes soft and yielding, 
as in osteo-malacia, with enlargement of its canals and cancelli. 

Causes. — Eachitis, as we have stated elsewhere, is entirely dis- 
tinct in its nature from scrofula. The scrofulous are not likely to 
become rachitic, nor the rachitic scrofulous. Proneness to low 
grades of inflammation or to hyperplasia of the lymphatic glands, 
which characterizes scrofula, seldom exists in connection with swell- 
ing of the bones or other manifestations of rachitis. The differ- 
ences between the scrofulous and rachitic diatheses, which indeed 
seem to exclude each other, are marked. The scrofulous are well 
developed and of good height, as a rule, while the rachitic are 
stunted. Scrofula manifests itself not less frequently in childhood 
than in infancy, whereas rachitis we have seen is especially a dis- 
ease of infancy. Again, as showing the difference between the 
two, scrofula is not infrequently associated with tuberculosis, 
whereas rachitis with tuberculosis is rare. 

Eesidence in a cold and moist climate, or in dark, damp, and ill- 
ventilated apartments, is a cause of rachitis. Therefore it is more 
common in the north of Europe than in the warm and equable 
climate of southern Europe ; in the damp and dark basements and 
alleys of the city, than in dry and airy country residences. In 
deep valleys, shut out from the solar rays, rachitis is more common 
than among people of the same habits and social position living in 
elevated and sunlit localities. 

A common cause of rachitis is the use of insufficient or improper 
food. This has been ascertained not only from the history of rachitic 
children, but from experiments on animals. Diminution in the 
relative amount of lime and consequent softening of the bones 
have been produced in various animals by the use of scanty food, 
or food deficient in nutritive properties. Artificial feeding of young 
animals at the time when nature designed that they should be 
nourished by the mother's milk has had the same result. (Experi- 
ments by M. Jules Guerin and others.) Eachitis is more apt to 
occur in those who are prematurely weaned than in those who nurse 
the full time. Those are most likely to become rachitic in a marked 
degree, even fatally, who at the same time have scanty and impro- 
per food, and reside, in damp, dark, and insalubrious localities. 

An hereditary predisposition to rachitis must also be admitted, 
since infants born of rachitic parents are more likely to become 
rachitic than are those of healthy parentage. The mothers pre- 
sented traces of rachitis in 27 out of 71 cases observed by Bitter 
von Eittershain. A mother in habitual ill-health and poorly 



94 RACHITIS. 

nourished, though without actual disease during the period of 
gestation, is more apt to have rachitic offspring than is a mother 
whose health is habitually good. 

It is not true, as some have stated, that all that is required to 
produce rachitis is a certain lowering of the vital powers, since all 
greatly enfeebled infants would become rachitic, whereas only a 
portion of such present the anatomical changes which characterize 
this affection. Cachexia is, however, the important element in its 
causation, and therefore the rachitic state not infrequently super- 
venes on certain exhausting diseases, as the eruptive fevers, per- 
tussis, and entero-colitis. 

Anatomical Characters. 1st Stage. — M. Lebert says: "In 
rachitis the bone is diseased in all its histological elements, and the 
skeleton in its totality." It commences with proliferation of the 
periosteum and of the cartilages of the epiphyses. In the normal 
state the new tissue formed by this proliferation changes into bone 
by the deposit of the lime salts, that formed from the periosteum 
increasing the thickness of the bone ; that from the cartilages, their 
length ; but in rachitis, as already stated, the osseous change does 
not occur. Soon the areolae, which abound in the ends of the long 
bones, in the short bones, and in the diploe of the flat bones, are 
observed to enlarge, and the laminae of which the compact bone is 
composed, to separate more or less from -.each other, forming inter- 
lamellar spaces. 

The areolar and interlamellar spaces are filled with a gelatini- 
form fluid of a pale reddish color. The same substance fills the 
medullary canals, and, in certain situations, more or less of it is 
deposited between the periosteum and the external surface of the 
bone. The amount of subperiosteal deposit in a given place, de- 
pends in a measure on the tensity and degree of adherence of the 
periosteum. Thus when curvatures occur, the quantity of this 
substance deposited over the concave surface of the bone, where 
the periosteum is lax, is considerable, while over the convex sur- 
face, where it is tightly drawn, it is absent or scanty. This sub- 
stance adheres quite firmly to the surface of bone, with which it 
is in contact, though at autopsies more or less of it can be washed 
away by a stream of water. 

The periosteum and medullary membrane are more vascular than 
in their normal state, presenting a deep red color, and the vascu- 
larity of the bone itself is increased. 

2d Stage. — The second stage is that of curvatures and deformity. 
The laminae of compact portions, and the walls of the areolae, in 



EACHITIS. 95 

parts that are cancellous, become gradually thinner and more 
yielding. Here and there loss of the animal matter in connection 
with the mineral, occurs, producing new apertures and channels, 
in some of which bloodvessels of a new growth are developed. 
Occasionally portions of bone become detached, and lie as sequestra 
in the midst of the gelatiniform substance. The shape of the me- 
dullary cavity changes. The extremities of the cavity are con- 
siderably larger than its central portion. In this second stage, in 
typical cases, the relative proportion of calcareous matter being 
greatly reduced, and the new gelatiniform substance still semi- 
liquid, if an opportunity occur of examining the skeleton, the long 
bones can be bent, and their epiphyses, as well as the flat and short 
bones, compressed, and, in some instances, even crushed between 
the thumb and fingers. u The bones in this state can be cut with a 
knife with as much ease," says Trousseau, " as a carrot or other 
soft root. In cases in which the absorption has been considera- 
ble, if the bone removed from the cadaver is dried, it will be found 
possible to respire through it, so great is its porosity, and its weight 
is from six to eight times less than that of normal bone. 

If rachitis commence at an age, as it commonly does, when -the 
diaphyses and epiphyses of the long bones are united by cartilage, 
this cartilage not being transformed into bone increases in extent 
and undergoes molecular changes, which have been minutely de- 
scribed by M. Broca. According to him, as we examine the carti- 
lage beginning at the epiphysis, we find first a layer of cartilage 
which is but little changed, containing cells in their normal state. 
Nearer the diaphysis we find cartilage perforated with small holes, 
the cartilage cells, instead of being distinct, being arranged in 
longitudinal groups, in other words, lying in longitudinal cavities, 
and flattened by mutual pressure. Near the diaphysis bands of 
fibrous tissue surround the clusters of cells. 

"While the anatomical changes, described above, are occurring, 
the ligaments, which unite the bones, become gradually lengthened 
and relaxed, so that there is increased mobility of the bones upon 
each other. 

The deformities which occur in the second stage vary in degree 
in different cases, according to the amount of rachitic softening 
and tumefaction of the bones, and relaxation of the ligaments, on 
the one hand, and the movements of the patient on the other. If 
the patient is old enough to walk, the curvatures ordinarily occur 
first in the lower extremities; but if too young to walk, in the 
upper extremities. 



96 RACHITIS. 

Craniotabes. — Occasionally the cranial bones in rachitis become 
very much thinned and softened in places, to which the name of 
craniotabes has been applied. This thinning occurs most frequently 
in the occipital bone, and sometimes to such an extent that the 
dura mater and pericranium are nearly in contact. The soft spots 
are yielding when pressed upon, and in the cadaver they are seen 
to be translucent when held to the light. Craniotabes has been in- 
vested with considerable pathological importance, chiefly through 
the writings of Dr. Elsasser, more it is now believed than is war- 
ranted by the facts. 

The changes in the shape of the head in rachitis are character- 
istic, and are so manifest as at once to attract attention. The 
growth of the cranium is not retarded like that of other parts of 
the system, and in some patients its volume is greater than the 
normal size. If there is considerable cranial development, hyper- 
trophy or hydrocephalus commonly coexists. The rachitic skull 
does not always present the same shape. It may be elongated, but 
more frequently it approximates to a square shape. It is more or 
less flattened superiorly, laterally, anteriorly, and posteriorly. The 
sutures, which are late in closing, are commonly depressed, while 
the frontal protuberances are unusually elevated. Elevation of the 
sutures in ridges has been observed in exceptional cases, as also 
flattening limited to one plane of the head, or greater in one than 
in the others, so as to destroy the symmetry of the cranium. 

The deformities of the trunk and limbs occurring in the second 
stage are interesting. There is lateral depression of the thoracic 
walls between the second or third and ninth ribs, accompanied by 
projection of the sternum. The shape of the chest resembles that 
of the prow of a ship, to which Glisson likened it, or the breast 
of a bird. This deformity is the result of atmospheric pressure, 
occurring externally upon the thoracic walls during inspiration, 
at the time when the ribs are most softened, and least elastic. 
Depression of the first and second ribs is partially prevented by the 
support which they receive from the clavicles. The length of the 
clavicles is, however, somewhat diminished, and their curvatures 
increased, so that the shoulders approach each other. Below the 
ninth ribs the thoracic walls are expanded ; the corresponding ribs 
on the two sides are more separated from each other than in their 
normal state. The expansion of the base of the chest diminishes 
tjie convexity of the diaphragm, and causes depression of the liver 
and spleen. 

The abdomen in rachitis is protuberant, partly on account of the 



RACHITIS 



97 



depression of the liver and spleen, partly on account of the spinal 
curvatures and shortening of the trunk, but chiefly on account of 
the fact that in this disease the intestines are distended with gas. 
The meteorism gives rise to tympanitic resonance on percussion, 
except occasionally over the lower part of the abdominal cavity, 
where there may be dulness from serous effusion. 

Spinal curvatures, to which allusion has been made, are common 
in rachitis. They are due to softening of the intervertebral carti- 
lages, and the bodies of the vertebrae, and to laxity of the inter- 
vertebral ligaments. Their direction is commonly antero-posterior. 
They are distinguished from the deformity of caries by the absence 
of an angular projection. Moreover, except in cases of long con- 
tinuance, the curvature can be removed by placing the patient in a 
horizontal position, and pressing with the fingers on the projecting 
parts. The pelvic bones also undergo change of shape. There is 
expansion of the upper part of the pelvic cavity, from the pressure 
of the abdominal viscera, corresponding with the expansion of the 
lower part of the thorax, though not in as great degree, while the 
lower part of the pelvic cavity is contracted. 

The bend of the humerus is such in most patients that its con- 
cavity looks inwards and forwards, but occasionally it is directly 
the opposite. The concavity upon the forearm corresponds with the 





palmar surface of the hand. The concavity of the thigh presents 
towards the median line and a little posteriorly. The natural bend 
of the femur being simply increased. The curvatures of the tibia 
and fibula vary in different cases. If the infant has not walked, 

7 



98 RACHITIS. 

their concavity is commonly directed forwards and inwards; but 
if it has walked, outwards and backwards. Occasionally, the di- 
rection of the bend on one side differs from that on the other. 

3d Stage. — The third stage is that of reconstruction. After a 
variable period, depending on the severity of the disease and the 
state of the constitution, the gelatiniform substance becomes more 
consistent, and points of calcareous matter appear here and there 
within it. The deposit of lime-salts continues, and the newly-formed 
bone again becomes firm and unyielding. It is generally cancellous 
in places where the original bone was of this character, though the 
extent of the new cancellous structure is apt to be different from 
that in the normal bone. Thus not only are the epiphyses cancellous 
in the new as in the original bone, but I have seen the entire me- 
dullary cavity filled with cancellous structure. The sub-periosteal 
deposit is sometimes also transformed into cancelli. This was the 
character of the change occurring under the pericranium in one spe- 
cimen which I examined. Where the original bone was compact, 
the reconstructed bone is usually of the same character, as, for ex- 
ample, in the shafts of the long bones. Compact portions of the 
reconstructed skeleton have been said to lack the elements of true 
bone ; they are osteoid, according to this theory, and not osseous, 
resulting from petrifaction of the gelatiniform substance. I have, 
however, found the elements of true bone in the skeletons of two 
individuals who had well-marked rachitic curvatures. The por- 
tions examined were removed from the concavities of the long 
bones, where there had been decided bending and thickening of 
the shafts from the large amount of rachitic deposit. In both 
specimens the osseous corpuscles (lacunce) and Haversian canals 
were easily demonstrated ; but in both there had been considerable 
growth of the bones since the rachitic period, and perhaps the 
portions which were examined belonged to this subsequent growth. 
Whether or not true bone is produced in the third stage of rachitis, 
■that is, from the deposit of calcareous salts, which immediately 
^succeeds the softening, certainly in the subsequent growth there 
iis the formation of true bone. 

Such is a brief sketch of the changes which the skeleton under- 
goes in ordinary cases of rachitis. An extreme degree of softening 
may be reached in four or five months, or not till the lapse of a 
year or more. The third stage, or that of consolidation, lasts one 
or two years. While in the first and second stages there is an arrest 
of ossification, and a deficiency of calcareous salts in the system, 



COMPLICATIONS. 99 

there is often in the third stage, as Lebert has stated, an exube- 
rance of ossification, and a superabundant deposit of the salts of 
lime, so that the reconstructed bone is firmer and stronger than 
normal bone. 

Occasionally, in reduced states of system, the third stage does 
not occur. The bones remain very soft and flexible, consisting 
almost entirely of animal matter. This is what has been desig- 
nated rachitic consumption of bone. Such cases end fatally after 
a variable time. 

A not unfrequent accident in the second period of rachitis is 
fracture in the shafts of the long bones. If there is almost com- 
plete removal of the mineral substance of a bone, so that the peri- 
osteum incloses little except the gelatiniform deposit, and the 
animal matter of the old bone, the limb bends readily, and no 
fracture occurs. If there is not so complete absorption, the weight 
of the body or muscular exertion snaps rather than bends the 
weakened shaft. From the nature of the fracture, crepitation 
can rarely be produced. The callus is not generally abundant, and 
reunion of the bone is slow. Many cases of rachitic fractures are 
partial, portions of the shaft deprived of the mineral element bend- 
ing, while the part which retains this element is fractured. 

Rachitis retards the evolution of the teeth. If the disease, 
commence as early as the fifth or sixth month, no teeth commonly 
appear till after the age of twelve months ; if certain teeth have 
appeared prior to the rachitic disease, an interval of several months 
elapses before the next are cut. Teeth which are developed during 
the rachitic state are frail, and deficient in enamel. They become 
black and carious early, and loosen in their sockets. If there is 
no tooth at the age of twelve months, the infant is probably ra- 
chitic. The fontanelles and cranial sutures remain open longer 
than in healthy infants. The former may not close till the third 
or fourth year, and the latter not till the second or third year. 
Patency of the anterior fontanelle after the age of twenty months 
indicates rachitis. 

Although the prominent and most interesting lesions of rachitis 
occur in the bones, anatomical changes, resulting from the dis- 
ease, occasionally occur in the soft parts. The lymphatic glands, 
liver, spleen, and some other organs not infrequently undergo 
waxy degeneration, diminishing greatly the chances of recovery. 
Whether this degeneration results from the diathesis directly, or 
is due to the bone disease, the substance which is produced is now 



100 EACHITIS. 

admitted to be the true waxy material, though for a time denied, 
as it does not always give a clear reaction with iodine. 

Rachitis influences the future growth of the skeleton. The long 
bones, though unusually thick and firm, do not attain the normal 
longitudinal development ; therefore the child of ten years, who 
has had rachitis, is scarcely taller than one at six who has not been 
thus affected. In many patients the curvatures in the course of 
time gradually diminish, so that in youth and maturity the body 
is less misshapen than at the age of two or three years. It is rare, 
however, that the deformities entirely disappear. 

It is seen that the anatomical characters of rachitis resemble, in 
certain respects, those pathological processes which are admitted 
to be of an inflammatory nature. The tenderness, hyperemia, pro- 
liferation, and consequent thickening of the periosteum, and the 
proliferation of the epiphyseal cartilages, are perhaps inflamma- 
tory, since they resemble more closely the lesions of inflammation 
than any other recognized pathological state. The soft substance, 
which is produced so abundantly in places underneath the perios- 
teum and in the spaces of the bone, is perhaps in part an exuda- 
tion, and in part the animal matter which is formed in the normal 
development of the bone. The immediate cause of the elimination 
of the lime salts from the kidneys, and the consequent arrest of 
ossification of the skeleton, is unknown, but it has been suggested 
that as a large proportion of the rachitic suffer previously from 
indigestion and diarrhoea, with the formation of acids in the pri- 
mse vise, especially the lactic, an acid in the blood holds the lime 
in solution, and hence its elimination. But however plausible this 
theory may appear, it lacks demonstration as yet. 

Symptoms. — The patient in incipient rachitis is quiet and melan- 
choly, shunning caresses or attempts to amuse him, since movement 
of his body increases his suffering. He has general tenderness, 
due in part to the morbid state of the periosteum, and in part to 
hyperesthesia. The rachitic infant, therefore, unless very mildly 
affected, will evince anxiety and dread even at the approach of 
one, through fear of being touched or moved. Trousseau says 
" this change in the character of the infant, the fear which it ex- 
periences of seeing its sufferings return, which the pressure of 
another's hand causes, this habitual sadness impressed upon its 
features, differs from that which we observe at the commencement 
of other maladies, especially from that in the prodromic period 
of cerebral fevers. In truth, in an infant over whom this last 



SYMPTOMS. 101 

and cruel affection is impending, we are able to excite again a 
momentary cheerfulness; we are able, by exciting actively its 
spirits, to make it turn temporarily from this melancholy languor, 
which constitutes its habitual state. It is not thus in the rachitic ; 
the more you desire to arouse it, the more you solicit its move- 
ments, the greater will be its impatience. It is indifferent to the 
plays which it previously loved. This * * * habitual sadness in 
an infant, who, with an appetite rather augmented than dimin- 
ished, sensibly emaciates, who has constantly acceleration of pulse 
coincident with profuse perspiration, these symptoms, I repeat, 
have positive significance when the infant does not cough or 
present any of the signs which induce us to believe in the occurrence 
of tubercular phthisis." 

Febrile movement, manifested by acceleration of pulse, is com. 
mon, although, in most cases, there is no decided exaltation of- the 
external temperature, perhaps in consequence, in part at least, of 
the free perspiration to which these patients are subject. 

A bruit de soufiiet of greater or less intensity, synchronous with . 
the pulse, has frequently been heard in rachitic cases, when the ear 
was applied over the anterior fontanelle. Drs. Fisher and Whitney, 
New England physicians, first called attention to this murmur, be 
lieving it to be a sign of chronic hydrocephalus. MM. Rilliet and 
Barthez heard it in cases of rachitis, and therefore concluded that 
the American observers had mistaken the rachitic for the hydro- 
cephalic head. Later observations have established the fact that 
this murmur possesses little diagnostic value. It is heard in 
healthy as well as diseased infants. Dr. "Wirthgen detected it 22 
times in 52 children, all of whom, except 4, were in good health. 
I have auscultated the anterior fontanelle in 29 infants, who were, 
with two exceptions, between the ages of three and thirty months. 
Most of them were well, or with trivial ailments, which would 
not affect the cerebral circulation. In most infants with a patent 
fontanelle a murmur can be distinctly heard synchronous with the 
respiratory act, and in 15 of the 29 cases no other bruit could be 
detected, while in the remainder, namely 14, a bruit synchronous 
with the pulse was heard at the fontanelle. 

The rachitic, as stated above, are liable to perspirations, which 
are profuse about the head and neck, so as to moisten the pillow 
on which they lie. The respiration is more or less accelerated ex- 
cept in the mildest cases, in consequence of the flexibility and 
diminished elasticity of the ribs, and the lateral depression of the 
thoracic walls, which prevent full inflation of the lungs. 



102 RACHITIS. 

The urinary secretion is abundant, like the perspiration. During 
the first and second periods it contains a large amount of the cal- 
careous salts, since the lime which enters the system with the in- 
gesta, and which, in the normal state is expended in the growth 
of bone, is eliminated from the system by the kidneys. 

The appetite in the beginning of rachitis is good, sometimes 
even better than in health, but it gradually diminishes, as the dis- 
ease increases in severity, till it is entirely lost. Diarrhoea alter- 
nating with constipation is common. "With the continuance of 
febrile movement and loss of appetite, the patient soon begins 
to lose flesh, emaciation in the second stage being a prominent 
symptom. 

Since the rachitic patient sits or lies quietly, unable or disinclined 
to make exertion, the muscles become small and flabby from dis- 
use. Deposition of fatty matter may occur between the primi- 
tive muscular fasciculi. 

Rachitis in the female infant is attended by one serious conse- 
quence, namely, narrowing of the pelvic cavity, from the thicken- 
ing, change of shape, and imperfect development of the pelvic bonesv 
Rachitis, therefore, in the female greatly increases the danger of 
child-bearing, and may render it impossible. 

Complications. — Rachitis is often attended by certain serious com- 
plications, the most common of which are inflammatory affections 
of the respiratory apparatus. Bronchitis is one of the most com- 
mon diseases during the age at which rachitis occurs, and even a 
mild form of it involves great danger if the ribs are soft and flexi- 
ble or the thorax have the rachitic deformity. In these cases,, 
since full inflation of the lungs is prevented, collapse more or less 
complete of certain of the lobules is apt to occur, increasing the 
amount of dyspnoea, and therefore diminishing the chances of re>- 
covery ; hence bronchitis is very fatal in infants who are decid&dly 
rachitic. 

Imperfect digestion of food, and unhealthy alvine evacuations,, 
common in rachitic children, frequently cause diarrhoea, and, after 
$ time* intestinal inflammation. The diarrhoea, especially if it has 
become inflammatory, is apt to be obstinate and dangerous, thas 
patient becoming emaciated and feeble. 

Internal convulsions, the so-called laryngismus stridulus or spasm 
of the glottis, has been observed in so large a proportion of cases, 
that its occurrence in rachitis must be considered something more 
than mere, coincidence, Elsasser believed that he had discovered 



TREATMENT. 103 

the cause of the laryngismus in craniotabes, but later observations 
have failed to establish the correctness of his views. Hypertrophy 
of brain, and chronic hydrocephalus, are also occasional complica- 
tions. In cases of great deformity of the chest from rachitis, in 
which the lungs are more or less compressed, the pulmonary circu- 
lation is retarded and imperfect. This gives rise to congestion of 
the right cavities of the heart, with hypertrophy of this organ, 
and congestion of the hepatic veins, liver, and portal system. 
Congestion of the portal system may be regarded as a cause of the 
diarrhceal attacks. 

Diagnosis. — Diagnosis is easy except in incipient or slight cases. 
The lesions which pertain so largely to the skeleton are readily de- 
tected. Beading of the costo-chondral articulations occurs early, 
and is apparent to the sight. Enlargement of the joints of the 
limbs, arrested dental evolution, the state of the anterior fontanelle, 
the peculiar shape of the head, the sternal projection, and rachitic 
curvatures, indicate positively the rachitic state. Profuse perspira- 
tion upon the head and neck, and the general tenderness of the 
patient, as evinced by his cries when moved or disturbed, are also 
important diagnostic signs. 

Prognosis. — The prognosis is favorable, as regards life, if rachitis 
is recognized at an early period, and properly treated. The vicious 
nutritive process may be arrested, and the patient recover with but 
slight deformity. If curvature of the long bones has occurred, 
and the head and thorax are misshapen, the patient under favora- 
ble hygienic conditions commonly recovers from rachitis, but with 
permanent deformities. 

If there is that degree of spinal curvature in the dorsal region, 
and depression of the ribs, that respiration is, habitually, more or 
less accelerated and embarrassed, on account of compression of the 
lungs, the prognosis is unfavorable, since bronchial or pulmonary 
inflammation, occurring in this condition, is apt to be fatal. If 
there is much emaciation, and especially if diarrhoea is present, or 
of frequent occurrence, the prognosis should be guarded. In these 
cases there is probably waxy degeneration of important organs, 
which cannot be remedied. 

Treatment. — The correct treatment of rachitis is obvious when 
we consider its character and the nature of its causes. The indi- 
cation is to restore healthy nutrition. This requires both hygienic 
and therapeutic measures. The apartment in which the child re- 
sides should be dry, airy, and plentifully supplied with light. He 



104: SCROFULA. 

should be taken daily into the open air, in order to invigorate his 
system, but in such a way as not to increase his suffering, in con- 
sequence of his general tenderness. The diet should be appropriate 
for the age. It should be bland and easy of digestion, and, at 
the same time, sufficiently nutritious. Cleanliness of person and 
apartment, and clothing sufficient to protect from vicissitudes of 
temperature, are requisite. The rachitic patient of the city should, 
if practicable, be removed to a well-selected locality in the country. 

The medicines which are of undoubted efficacy in rachitis are 
cod-liver oil, and the vegetable and ferruginous tonics. Cod-liver 
oil should be administered in cases in which the digestive function 
is not seriously impaired. If the oil is not readily digested, if it 
diminish the appetite, or if the patient is affected with diarrhoea, 
it should not be administered. Positive harm may, under such 
circumstances, result from its use. 

The citrate of iron and quinine, wine of iron, iodide of iron, the 
various preparations of cinchona, columbo, etc., are the medicines 
which, with or without cod-liver oil, are best calculated to restore 
healthy nutrition. When complications arise, the treatment should 
be modified to meet the exigencies of the case. Most of the diseases 
which occur as complications require treatment similar to that 
which is appropriate in their idiopathic form, but all measures of 
a depressing nature should be avoided. 



CHAPTER II. 

SCROFULA. 

The term scrofula (scrofa, a pig, from the resemblance of the en- 
larged cervical glands of a scrofulous individual to a swine's neck) 
is applied to a diathesis which is characterized by increased vulner- 
ability of the tissues (Virchow). The nutritive process of the 
tissues is readily disturbed even by trifling irritants or agencies in 
those who possess this diathesis, and therefore the scrofulous are 
very prone to hyperplasia of the lymphatic glands, and inflamma- 
tions of various parts. Inflammations which can properly be con- 
sidered as dependent upon this diathesis are, for the most part, 
subacute or chronic, and they are apt to occur in tissues which are 



CAUSES. 105 

seldom inflamed in those who possess a sound constitution. Inflam- 
mation of a scrofulous nature differs from ordinary inflammation 
in the fact of a greater cell formation, and greater liability to 
cheesy degeneration of the inflammatory products. Moreover, the 
diathesis often modifies those inflammations to which all persons 
are subject whether scrofulous or non-scrofulous, as coryza or 
bronchitis, rendering them more protracted and less amenable to 
the ordinary treatment. 

Scrofula is a disease chiefly of infancy and childhood. Manhood, 
especially the first years of it, is not entirely exempt, but scrofulous 
manifestations after the age of twenty are feeble and infrequent, 
disappearing entirely as the individual advances towards middle 
life. The diathesis is most active prior to the age of ten years. 

Causes. — Scrofula is congenital or acquired. Parents who had 
scrofulous symptoms in early life, or who are in a state of decided 
cachexia, as from cancer, syphilis, intermittent fever, or tubercu- 
losis, are apt to beget scrofulous children. Insufficient nourishment 
of the mother during a considerable part of her gestation, and 
advanced age, and therefore feebleness, of the father, are occasional 
causes. Near blood relationship of the parents is recognized as a 
cause by most who have written on this diathesis, and to this fact 
has been attributed the scrofula of royal families, though probably 
with insufficient proof. 

Again, those born with sound constitutions may acquire scrofula 
through anti-hygienic influences in the first years of life. Among 
the poor of New York we often observe one child in the family 
who presents scrofulous symptoms, while the rest of the children 
are well, and in many cases we are able to trace back the diathesis 
to some depressing cause or causes, which were sufficient to effect 
the peculiar change in the molecular condition of the tissues which 
constitutes this disease. Obviously the causes of acquired scrofula 
are quite numerous. In the infant it is sometimes produced by 
insufficiency or poor quality of the breast milk, or the use of artifi- 
cial food during the period when breast milk is required. Too pro- 
tracted lactation also, especially if artificial food is almost wholly 
withheld, may cause it, as may also, in those who have passed be- 
yond the age of lactation, the continued use of a diet which is 
deficient in nutritive properties. 

Residence in damp, dark, and filthy apartments or streets may 
also produce it. Hence, one reason of its frequent occurrence 
among the city poor. Eesidence in a small, crowded, and imper- 



106 SCROFULA. 

fectly ventilated apartment has been known to produce it, even 
with personal cleanliness, and a diet sufficiently nutritive. 

Scrofula may also be produced in those previously robust and of 
sound constitution, by diseases of an exhausting nature. The erup- 
tive fevers, as smallpox, measles, and scarlet fever, if severe, occa- 
sionally have this result, or they render active the diathesis, which 
had hitherto been latent. In this city, where chronic entero-colitis 
of infancy is common, I have sometimes been able to trace the 
diathesis to it. 

Can a child affected with scrofula communicate it to others? 
Does scrofula possess a peculiar principle, a materies morbi, which 
is communicable to others ? No one believes in the infectiousness 
of scrofula, but there is a strong popular belief that it is communi- 
cable by contact, and some good pathologists and high authorities 
in children's diseases are inclined to believe that the popular opinion 
does have some foundation in fact. M. Bouchut, who holds that 
the scrofulous and tubercular diatheses are identical, says of scrofula 
that it has not been shown to be inoculable. " Nevertheless, if its 
contagiousness has not been demonstrated, we are not able to say 
that it will not be some day. The facts of vaccinia followed by 
impetigo, by scrofulous ophthalmia, and enlargement of the cervi- 
cal glands attributed to the inoculation of scrofulous vaccine virus, 
and those of the contagion of phthisis by constant cohabitation, 
demand, at least for the present, a certain reserve." 

But scrofula differs widely in its nature from those diseases 
which are known to be communicable by infection or contact. It 
presents no analogy with them. We would not suppose, apart 
from observations, that a diathesis which consists in such a state 
or constitution of the tissues that they are easily wounded, pos- 
sessed any inoculable principle, and, in my opinion, observations 
go to show that no such principle exists. How often do we observe 
children with scrofulous coryza, otorrhcea, or scrofulous cutaneous 
eruption, associating with others without communicating the dia- 
thesis ? 

Vaccination, however, affords the best opportunity for determin- 
ing whether scrofula is inoculable, and the very prevalent opinion 
of non-professional people, that it may be communicated and es- 
tablished through this operation, should have due weight. For it 
may be stated, as a rule, that a wide-spread popular belief in refer- 
ence to a disease, which has external manifestations, does have 
some foundation in truth. 



CAUSES. 107 

The following are the facts in reference to this matter : — 

1st. It is the almost unanimous opinion of the most experienced 
vaccinators that pure vaccine lymph taken from a vesicle prior to 
the eighth day, never communicates anything but vaccinia. "When 
another disease, as syphilis, is communicated by the use of the 
lymph, it is through the blood, which has been mixed with the 
lymph by careless puncture of the vesicle. This opinion, so strongly 
established by observations, also commands assent from its reason- 
ableness. 

2d. Vaccination of those who are decidedly scrofulous with 
virus from a healthy child, especially if the scab is employed, not 
infrequently produces a sore which becomes covered with a thick 
and irregular crust, consisting in part of inspissated pus, and the 
sore is long in healing. In the scrofulous, also, impetiginous erup- 
tions are apt to arise around the vaccine sore, and the axillary 
glands to become tumefied on the side corresponding with the 
vaccination. This gives rise to the belief on the part of friends 
that impure virus has been used, and scrofula communicated, while 
the fault is in the constitution of the child itself. The tumefac- 
tion of the glands, and the primary and secondary sores, gradually 
disappear, in most cases, leaving no ill effects, and with no subse- 
quent manifestations of disease. 

3d. The vaccine crust from a decidedly scrofulous child, as it 
contains more or less animal matter, and is often pale, irregular, or 
broken, inserted in the arm of a healthy child, not infrequently 
produces an immediate infiammatioD with suppuration, so that the 
vaccine vesicle, if it forms, is soon broken, and an irregular sore and 
crust result, which present none of the appearances observed in the 
uncomplicated vaccine eruption. A simple inflammation, produced 
by the pus or other products contained in the scrofulous scab, has 
coexisted with, and modified, the specific eruption. The sore heals 
gradually, and impetiginous eruptions may occur around it, but no 
struma remains or is communicated. 

4th. Scrofulous manifestations sometimes appear for the first 
time after vaccinia, but they appear also after those analogous but 
severer eruptive fevers, namely, measles, scarlet fever, and small- 
pox. Those infectious exanthematic diseases which profoundly 
affect the constitution, it is admitted, may be a co-operating, if not 
a main, cause of scrofula, and is there anything unreasonable in the 
supposition that vaccinia may have occasionally a similar effect, 
though less frequently or in a less degree, in proportion as it is 
milder? From my own observations, I am of opinion that vaccinia, 



108 SCEOFULA. 

not vaccination, may occasionally awaken to activity the scrofulous 
diathesis, or, in combination with other causes, may even produce 
it in those who previously possessed sound constitutions. It is a 
well-established fact, in the etiology of diseases, that causes which, 
in themselves, are entirely inadequate, or even insignificant, fre- 
quently produce disease in a system which other agencies have 
already prepared for it. Thus an excoriation gives rise to erysipelas, 
or a slight exposure to cold produces rheumatism. And so in those 
cases in which the friends have charged the production of scrofula 
upon vaccination, it has seemed to me that the most that could, 
with truthfulness, be alleged, was that the constitutional disease 
which had been produced by the operation, namely, vaccinia, was 
a subordinate, but, under the circumstances, a sufficient cause. 

The following is the most striking case of the apparent commu- 
nication of scrofula through vaccination which I have met : D , 

West Fortieth Street, residing in a tenement-house, had no scrofu- 
lous affection, and was considered healthy till the age of eleven 
years. The remaining children of the family have never exhibited 
scrofulous symptoms. At the age of eleven years this boy was 
vaccinated from a scab, the source of which was not known, but by 
a physician whose practice was chiefly among the city poor. The 
sore produced was long in healing, and, before it had healed, the 
axillary glands, and those of the face and neck, began to be 
prominent and hard. From this time to the present, a period 
of six years, these glands have remained so large as to constitute 
a deformity, and certain other groups of glands, as those in the 
left infra-clavicular region and right groin, have undergone a 
similar hyperplasia. Examination of the blood by the microscope 
shows the absence of leucocytheemia. This case, at first view, 
certainly appears to be an example of the communication of scro- 
fula through vaccination, and, for a time, I could interpret it in no 
other way. But when we recollect the facts already stated, namely, 
the improbability of the communicability of a diathesis of such a 
nature, how frequently scrofula is acquired by children of the 
tenement-house population, solely through the anti-hygienic condi- 
tions in which they live, the large number of scrofulous children 
in the crowded quarters of the poor, many of which have external 
ailments so that the conditions of its communication are present 
if it were in any way contagious, when, I say, we recollect these 
facts, is it not probable that cases like this, which are certainly 
rare, are to be explained in the manner indicated above, and that 
scrofula is not transmissible by vaccination. The facts, therefore, 



ANATOMICAL CHARACTERS. 109 

if they do not prove a lack of contagiousness, at least render it 
probable. 

Anatomical Characters. — There are no ascertained anatomical 
changes in the blood which are peculiar to scrofula. As long as 
the appetite and general health remain good, and the local affec- 
tions have not occurred, the composition of this fluid is, so far as 
known, unaltered. In the cachexia, which occurs when the gene- 
ral health is impaired, the blood becomes impoverished, the red 
corpuscles lose a portion of their coloring matter, and the watery 
element predominates. 

Does the glandular hyperplasia of scrofula produce an excess of 
the white corpuscles? Virchow says (Cellular Pathology, Lect. 
IX.), " During the progress of an attack of scrofula, in which, if 
the disease run a somewhat unfavorable course, the glands are de- 
stroyed by ulceration, or cheesy thickening, calcification, etc., an 
increased introduction of corpuscles into the blood can only take 
place as long as the irritated gland is still, in some degree, capable 
of performing its functions, or still continues to exist ; as soon, 
however, as the glands are withered or destroyed, the formation of 
lymph cells likewise ceases, and with it the leucocytosis. In all 
cases, on the other hand, in wdiich a more acute form of disturbance 
prevails, connected with, inflammatory tumefaction of the gland, 
an increase of the colorless corpuscles always takes place in the 
blood." Although the glandular hyper plasia occurring in scrofula 
increases the number of white corpuscles in the blood, scrofula 
cannot be regarded as sustaining any causative relation to that 
great and constant increase of white corpuscles which constitutes 
the disease leucaemia ; for this disease, as remarked by E"iemeyer, 
does not occur in childhood, when the scrofula is active, but in 
manhood, when the scrofulous diathesis has become latent. 

The anatomical change which a lymphatic gland, when it be- 
comes the seat of scrofulous disease, undergoes, consists in an ex- 
aggerated production of the lymphatic cells, while an increase in 
the amount of stroma is quite subordinate, or none at all. The 
hyperplasia sometimes occurs gradually, and without the signs 
characteristic of inflammation ; in other cases it presents all the 
features of a true inflammatory process. Caseous degeneration is 
the more apt to occur, the larger the number of newly-formed 
cells, and the greater their mutual pressure. 

The hyperplasia is sometimes primary, a direct result of the 
diathesis. In other instances it is secondary to some adjacent in- 
flammation, the morbid process being propagated along the lym- 



110 SCEOFULA. 

phatic vessels. Thus, while primary hyperplasia of the cervical 
glands is not infrequent in children who have a decided scrofulous 
diathesis, secondary hyperplasia of these glands is more frequent. 
It results from eczema of the scalp, or face, or otitis, or any of the 
various forms of stomatitis. And so pharyngitis often gives rise 
to hyperplasia of the tonsils, which are lymphatic glands. The 
scrofulous nature of the glandular enlargement is apparent from 
the fact that it continues long after the primary inflammation 
which gave rise to it has abated ; for lymphatic glands sometimes 
become tumefied in those who are not scrofulous, either from 
direct injury or propagated inflammation ; but the tumefaction is 
commonly less in degree, and in most instances it soon abates 
when the exciting cause is removed. 

The glands which most frequently undergo scrofulous enlarge- 
ment are the cervical, inguinal, bronchial, and mesenteric, but in 
those who are highly scrofulous, the glands in the vicinity of any 
protracted inflammation are very prone to hyperplasia, and some- 
times become cheesy. Thus, I have seen enlarged and cheesy 
glands in the vicinity of bone which was affected by scrofulous 
ostitis, or periostitis. 

Glands enlarged by scrofula frequently remain indolent for many 
months or years, undergoing no appreciable alteration, but they are 
liable to attacks of acute inflammation, when they enlarge, become 
tender, and the surrounding connective tissue infiltrated and hard. 
Suppuration is the common result, and the abscess, if subcutaneous, 
escapes through the skin, leaving a cicatrix which is permanent. 

More frequently, with proper therapeutic and hygienic measures, 
the glandular hyperplasia gradually abates after a longer or shorter 
period, probably by fatty degeneration, liquefaction, and absorp- 
tion of the redundant cells. Even when suppuration occurs in 
certain of the glands, others, and the majority, return to their nor- 
mal state in this gradual way. Calcification of a gland has been 
known to occur, but it is rare. 

In order to complete the description of the anatomical charac- 
ters of scrofula, it would be necessary to describe the various in- 
flammations to which the diathesis gives rise. It will suffice, 
however, in this connection, simply to enumerate them. Those 
which are most common and of chief importance, occur in the 
skin, mucous membrane, connective tissue, the bones with their 
periosteal covering, the joints, and the two important organs of 
special sense, the eye and ear. 

Symptoms. — The scrofulous diathesis is exhibited by certain phy- 



SYMPTOMS. Ill 

sical signs, which are present in infancy, hut are more manifest in 
childhood. In one class of strumous children, they are as follows: 
Form, tall and slender, quickness of movement and perception; 
intelligence, good ; skin, thin and semi-transparent, through which 
the superficial veins are distinctly seen; features, delicate; cheeks, 
habitually pale or florid, and flushed by slight excitement ; eyes, 
bright, with bluish conjunctiva; muscles and bones, slender in pro- 
portion to their length. Those children who present these pecu- 
liarities are said to have the erythitic form of the diathesis. 

Others have what has been designated the torpid scrofulous 
habit, which is characterized by softness and flabbiness of the flesh, 
distended abdomen, large head, broad face, slow, languid move- 
ments, and an over-production of fat in the subcutaneous connec- 
tive tissue in certain situations, especially the nose and upper lip. 
Though typical cases can be readily referred to one or the other of 
these forms, there are many cases which are intermediate. 

One of the earliest of the scrofulous manifestations is a subcu- 
taneous cellulitis giving rise to abscesses, commonly not large, with 
little surrounding induration, little pain, tenderness, and heat, and 
slow in discharging ; in a word, indolent. The most frequent seat 
of these abscesses is upon the extremities, but they may occur upon 
the scalp or elsewhere. They gradually heal when the pus escapes, 
their site being indicated for a considerable time by the depression 
and reddish discoloration of the skin, which gradually returns to 
its normal state. Ordinarily, these abscesses do no harm apart 
from the reduction of the general health which they effect, but 
when occurring in localities where the connective tissue lies upon 
the periosteum, as upon the fingers, periostitis may result, with de- 
struction of the surface of the bone. Again, thrombi may occur 
in the veins of the inflamed part, giving rise to emboli, embolismal 
pneumonia, and death. Specimens from such a case were presented 
by me to the ~Eew York Pathological Society in 1868. 

The scrofulous affections of the skin often also occur at an early 
age, even before dentition. They are more frequent in infancy than 
in childhood. The most common are eczema and impetigo, and 
of rarer occurrence, ecthyma and lupus. But all of these may 
occur in those who are not strumous or who do not present the 
characteristics of the strumous diathesis. 

Scrofulous affections of the mucous surfaces are scarcely less fre- 
quent than those of the skin. They present the ordinary features 
of mucous inflammations of a subacute and chronic character. 

Sometimes they occur without obvious exciting cause ; in other 



112 SCROFULA. 

cases there is an exciting cause, as exposure to cold ; but the in- 
flammation once established, continues on account of the diathetic 
condition. It is sometimes a matter of doubt whether a mucous 
inflammation is of such a character that it is proper to designate 
it scrofulous, especially if it occur upon such surfaces as are often 
the seat of ordinary inflammation. If the child has heretofore 
presented symptoms of scrofula, if the inflammation is subacute, 
and there is no apparent cause to originate or sustain it apart from 
the diathesis, it is probably of a strumous character. The diag- 
nosis is rendered more certain by observing the effect of anti-stru- 
mous remedies. The most frequent of these inflammations are 
coryza, tracheo-bronchitis, and conjunctivitis, the last being a part 
of the more general inflammation of the eye. More rarely, sto- 
matitis, pharyngitis, vaginitis, and, according to some, entero-colitis, 
are of a strumous character. Coryza gives rise to snuffling respi- 
ration, the formation of crusts around and within the nares, and 
excoriation of the upper lip. The tracheo-bronchitis is attended 
by thickening of the mucous membrane, increased production of 
mucous and epithelial cells, and a loud tracheal rale, accompanying 
each inspiration. 

Strumous inflammation of the mucous membrane of the trachea 
and bronchial tubes is not a very infrequent disease in this city. 
It sometimes originates in a simple inflammation from cold, or the 
tracheo-bronchitis of measles, or pertussis, but it is apt to continue, 
with its rales, cough, and scanty expectoration, for months, unless 
relieved by a proper course of treatment. 

Among the most common of the strumous affections, are inflam- 
mation of the eyelid, designated psorophthalmia, and that of the 
eye itself. The former is characterized by redness and thickening 
of the lids, detachment of the eyelashes, and inflammation and 
altered secretion of the "Meibomian glands;" the latter, namely, 
strumous ophthalmia, by pain, lachrymation, photophobia, and a 
moderate degree of hyperemia of the affected organ. 

Inflammations of the external and middle ear have their origin 
very generally in the strumous diathesis. Occasionally there is an 
exciting cause of the otitis, as an injury, or severe constitutional 
disease like scarlet fever. Protracted otitis, whether external or 
internal, and especially that form of it which leads to ulceration, 
destruction of the ossicles, and caries of the petrous portion of the 
temporal bone, it is proper, in a large proportion of cases, to regard 
and treat as strumous. 

Inflammations of the skeleton, whether of the periosteum, bones 



SYMPTOMS. 113 

themselves, or the joints, are common in childhood. They some- 
times occur without apparent exciting cause, but most frequently 
result from injuries of a trivial character. Some of the best ob- 
servers and highest authorities, as regards the surgical diseases of 
• children, both in this country and Europe, state that they do not 
consider these affections to be of a strumous nature ; while others 
regard them as manifestations of struma. After carefully examin- 
ing the reasons for this variance in opinion, I am convinced that 
the difference of views in reference to this matter occurs from a 
different understanding of the nature of scrofula. Those who state 
that the affections alluded to are not scrofulous, believe, so far as I 
have been able to ascertain, that scrofula and the tubercular dia- 
thesis are identical. As tubercles are not, as a rule, present in 
children who suffer from these affections, it is therefore held that 
these affections are not scrofulous. If those holding this belief 
were told, or could be made to believe, that scrofula is entirely dis- 
tinct from the tubercular diathesis, that it is merely a name applied 
to a diathetic condition in which the tissues are easily wounded, 
there would probably be but one opinion as regards the scrofulous 
nature of these inflammations. For, as I have often had an op- 
portunity to observe, they occur in a large proportion of cases from 
very trivial injuries, showing a highly vulnerable state of the 
tissues. 

Holmes, in his useful and eminently practical Treatise on the 
Surgical Diseases of Children, says of one of the most common of 
the affections alluded to, namely, morbus coxarius : " The affection 
in question occurs very frequently in strumous children, a circum- 
stance which has led to its being denominated strumous. * * * 
If by strumous be meant a state of the system which renders the 
subject of it prone to the deposit of tubercle in the viscera, I think 
that there is good reason for asserting that morbus coxarius often 
attacks children who are not strumous, i.e., who display no such 
tendency to the deposit of tubercle." Still, Mr. Holmes states " that 
there is that condition of the system which disposes its subjects to 
the development of low inflammations of various kinds," which is 
almost the full definition of scrofula, as understood by us. 

The stubbornness and frequent disastrous consequence of scrofu- 
lous inflammation of the skeleton is well known. Nearly every 
bone, as well as its periosteum, is liable to this form of inflamma- 
tion, but some are more frequently affected than others. Inflam- 
mation of the bone may terminate by resolution, by the formation 



114 SCKOFULA. 

of an abscess, or, and frequently, by carious or necrotic destruction 
of the bone itself. Necrosis is most apt to occur in the shafts of 
the long bones, caries in the spongy extremities of these bones, 
and in the spongy portions of the short bones. If abscesses form, 
the pus may finally escape from the system by a tedious ulcerative 
process, or, retained, may undergo cheesy degeneration. Scrofu- 
lous arthritis, if early detected and properly treated, may resolve, 
leaving no ill effect; otherwise, there is apt to be suppuration, 
ulceration, cartilaginous and osseous, and anchylosis. 

Scrofulous children are perhaps no more liable to inflammation 
of the internal organs than other children, but the inflammatory 
products are more liable to cheesy degeneration, and the prognosis 
is therefore less favorable. The most frequent of these inflamma- 
tions, and the one of chief interest, is pneumonia. Catarrhal pneu- 
monia, so frequent in early life, whether primary or secondary, in 
connection with measles, pertussis, etc., is a disease often involving 
grave consequences in those who are decidedly scrofulous ; since, 
instead of resolving, the affected lung-tissue presents strong ten- 
dency to caseous degeneration, ending in consumption of the lungs 
and death. I have most frequently noticed cheesy pneumonia 
during extensive epidemics of measles, as a complication or sequel 
of this disease. It may occur in those who are not scrofulous, if 
the vital powers are greatly reduced, but it is so much more com- 
mon in the scrofulous, that some recent writers have designated 
this form of inflammation by the term scrofulous, instead of cheesy, 
pneumonia. From the fact, however, of its sometimes occurring 
in the non-scrofulous, the term cheesy or caseous, especially, too, 
as it expresses the anatomical state, seems more appropriate. . 

Relation of Scrofula to Tuberculosis. — It is now almost uni- 
versally admitted that rachitis is entirely distinct in its nature 
from scrofula, although, till a recent period, some of the best 
writers upon diseases of children, as Barrier, held that it was one 
of the manifestations of the scrofulous diathesis. Although the 
peculiar anatomical changes in rachitis occur chiefly in the osseous 
system, which is so often the seat of scrofulous disease, yet the 
character of these changes is so different from those which are 
admitted to be of a scrofulous nature, and especially as a large pro- 
portion of the rachitic do not present evidences of a strumous 
diathesis, struma and rachitis are justly regarded as distinct dis- 
eases, and their coexistence in the same individual as a coinci- 
dence. 

Pathologists and writers on diseases of children are not agreed 



RELATION OF SCROFULA TO TUBERCULOSIS. 115 

as to the relation of scrofula to tuberculosis. Some, as M. Bouchut, 
hold that the scrofulous and tuberculous diatheses are identical, 
believing tubercles a late .manifestation of scrofula, while others, 
among whom occur the illustrious names of Jenner, Yirchow, and 
Villemin, deny their identity, though admitting their close rela- 
tionship. Let us consider the facts, some of which are of recent 
discovery, which show in what manner, or to what extent, scrofula 
and tuberculosis are related. 

1st. In scrofula the lymphatic glands are more frequently af- 
fected than any other part, a true hyperplasia of their cellular 
elements occurring. This hyperplasia occurs to a greater or less 
extent in the majority of marked cases, and, when persistent, is 
the most reliable sign of the diathesis. The cells, which are pro- 
duced so abundantly in scrofulous glands, are, to all appearance, 
identical in character with the cells of which tubercles are com- 
posed. In other words, the physiological type of the tubercle cell 
is the normal cell of the lymphatic gland, and the proliferation of 
this cell, as we have already stated, produces the enlarged gland 
of scrofula. But it is to be observed, as showing the difference 
between scrofula and tuberculosis, that this cell is never found in 
the affections admitted to be scrofulous, in any other situation 
than in these glands, where they exist normally ; whereas, in tuber- 
culosis, they are produced abundantly, not only in the lymphatic 
glands, but in various organs and tissues throughout the system, 
which contain no such cell in their normal state. Moreover, the 
origin of this cell in the lymphatic gland is, according to Yirchow, 
different in scrofula and tuberculosis. While in the former it is 
produced by segmentation of the lymphatic cells, in the latter it 
is produced from the cells or nuclei existing in the connective 
tissue of the gland, as it is in other situations. 

2d. It has already been stated that the products of scrofulous 
inflammation are very liable to cheesy degeneration. In children, 
indeed, cheesy degeneration more frequently results from the scro- 
fulous affections than from any or all other diseases. Take, in 
connection with this fact, the very important recent discovery that 
tubercles are caused, in a large proportion of cases, by particles of 
cheesy matter, detached from the main mass, and conveyed to the 
lungs or other organs, and we see another intimate relation between 
scrofula and tuberculosis. 

3d. While the above facts show the close relationship of scrofula 
and tuberculosis, other facts relating to their hereditary transmis- 
sion show, in my opinion, their non-identity. The children of 



116 SCEOFULA. 

syphilitic parents are very apt to acquire thereby a scrofulous 
diathesis, and be affected by scrofulous ailments, while they cannot, 
as a rule, be said to possess the tubercular diathesis, or exhibit any 
more tendency to tubercles than other children who are in a state 
of equal cachexia. This does not comport with the doctrine that 
scrofula and tuberculosis are identical, Again, the infant of the 
parent who has advanced tuberculosis exhibits a great liability to 
tubercles, and less in degree to scrofulous ailments. If the dia- 
thesis of scrofula and tuberculosis were identical, we would expect 
that a larger proportion of these infants would exhibit scrofulous 
manifestations, and a smaller proportionate number become tuber- 
cular, since scrofulous affections are so much more frequent than 
tubercles, 

4th. As favoring the view that there are two diatheses, writers 
have stated the fact, that the greatest liability to tubercles is at 
an age when scrofulous affections are rare, namely, from the age of 
twenty to thirty years. M. Bouchut attempts to reconcile this 
fact with his theory of one diathesis, by analogical reasoning, 
which does not seem to me to be sound. He holds that there are 
distinct groups of manifestations of the diathesis, according to the 
age or the time of its continuance, as in syphilis, and that tubercles 
are the last manifestation. But tubercles may occur at any age, 
even in infants of a few months. Indeed, they are more common 
at the age of two or three years than at ten or twelve. The rea- 
soning of M. Bouchut does not, therefore, appear to invalidate the 
argument, for how can we consider tuberculosis an advanced stage 
of scrofula, when it may occur at any age or at any period of those 
affected with scrofula ? 

5th. Recent investigations demonstrate that tuberculosis is less 
a diathesis than was formerly supposed, or than scrofula is admitted 
to be. That there is, and was previously, a tubercular diathesis in 
a majority who are affected with tubercles, cannot be denied ; but, 
on the other hand, there are those, and not a few, who become 
affected with tubercles from the operation of local causes solely, 
when there was no diathetic predisposition to them. Thus, an 
individual who has never presented any evidences of scrofula or 
tuberculosis, but whose system is perhaps in a reduced state from 
some cause, takes a pneumonia, and the inflammatory products, 
instead of undergoing absorption, become cheesy, and from this 
cheesy substance tubercles result in the manner already described. 
Local causes have developed a tuberculosis unaided by a diathesis. 
Such cases are not very unusual. Contrast with this the fact that 



PROGNOSIS. 117 

in the causation of scrofulous ailments the scrofulous diathesis 
always plays a conspicuous part. 

6th. The following fact may be inferred from the foregoing, but 
it is so important in this connection, as showing the difference be- 
tween scrofula and tuberculosis, that it is proper to consider it 
under a separate heading. Scrofula simply modifies the ordinary 
physiological or pathological processes, while in tuberculosis there 
occurs, in the tissue affected, a pathological process which is pecu- 
liar. Thus in tuberculosis there is produced from the connective 
tissue, or more rarely from epithelial cells, a cell which under no 
other circumstances is produced in these parts ; whereas if scrofula 
affects the same tissues, there is simply an increase in the normal 
histological elements or inflammation, with inflammatory products. 

Prognosis. — As scrofula may be acquired through anti-hygienic 
influences, so it may disappear or become latent through influences 
of an opposite character. Therefore the manifestations of scrofula 
may be limited to a brief period, or they may occur at intervals 
through the whole of childhood and the first years of youth. 
When the diathesis is inherited, and fostered by unfavorable cir- 
cumstances, the scrofulous affections appear earliest, are the most 
varied and severe, and continue longest. 

In most cases, with proper treatment, the prognosis is good, pro- 
vided there are no serious local ailments. Scrofulous manifesta- 
tions gradually disappear, the diathesis ceases or becomes latent, and 
the health is fully re-established. Though the general health is 
restored, certain scrofulous inflammations, continuing for a certain 
time, and reaching a certain grade of intensity, produce perma- 
nent deformity or impairment of function. In unfavorable cases, 
death may occur from exhaustion due to protracted suppurative 
inflammation, or from tuberculosis resulting from the cheesy pro- 
duct of a scrofulous inflammation. Again, if the function of a 
vital organ is permanently impaired by scrofulous disease, the prog- 
nosis of any subsequent inflammatory affection of that organ is 
rendered much less favorable. 

Treatment. Prophylactic. — Measures designed to prevent scro- 
fula are impossible without the co-operation of willing and intelli- 
gent parents. It is obvious that the prevention of congenital 
scrofula requires the treatment of disease or impaired health in 
the parent. If parents should be taught or should remember that 
good health in themselves is the necessary condition of the inheri- 
tance of a sound constitution in the child, and should adopt such 



118 SCROFULA. 

therapeutic and regimenal measures as would procure this, the 
number of cases of inherited scrofula would be materially reduced. 

As the first years of life are very important, both for correcting 
the diathesis when inherited, and for preventing its development 
in those of sound constitution, care should be taken that the regi- 
men of the child be such as would in no way produce deterioration 
of the general health. The nursing infant, if the mother is in 
poor health, should be provided with a healthy wet-nurse, for in 
young children the diathesis may be acquired solely by the use of 
food that is scanty or of poor quality. Those old enough to be 
weaned should have plain and nutritious diet, with a proper ad- 
mixture of animal food. More or less out-door exercise, and a 
residence in a salubrious locality with sufficient air and sunlight, 
are requisite. 

Curative. — As scrofula originates in a state of weakness exist- 
ing in the parent in the congenital, and in the child in the acquired, 
form of the disease, and is characterized by feeble resistance of 
the tissues to irritating agents, the inference is reasonable that all 
tonics have, to a certain extent, an anti-scrofulous effect upon the 
system. The ordinary vegetable tonics, and sometimes the ferru- 
ginous, are indeed useful in the treatment of scrofula. Employed 
in connection with proper regimenal measures, they are sufficient, 
in many cases, to remove the diathesis after a time, or render it 
latent. Besides these medicinal agents, which tend to correct the 
scrofulous diathesis by their general tonic effect, there are certain 
others which experience has shown to be beneficial in the treat- 
ment of scrofulous affections, and which are, therefore, largely 
used. One of these is cod-liver oil, which contains iodine with 
numerous other ingredients. 

Cod-liver oil is useless or nearly so in the torpid form of the 
diathesis, which is characterized by an increased deposit of fat in 
the subcutaneous connective tissue, slow circulation, and sluggish 
muscular movements. On the other hand, in the treatment of the 
erythitic form it possesses real value. Its protracted use in such 
cases does so modify the molecular condition of the tissues that 
they are less liable to inflammation, and the diathesis is, therefore, 
rendered milder or removed. From one to three teaspoonfuls, ac- 
cording to the age, should be given three times daily. While we 
frequently experience so much difficulty in administering it to 
adults affected with tuberculosis, and sometimes find it necessary 
to discontinue its use on account of its nauseating effect, scrofu- 



TKEATMENT. 119 

lous children rarely refuse to take it, and it does not seem to di- 
minish their appetite. 

Iodine is justly celebrated as a remedy in the treatment of scrofu- 
lous affections, but it is a question whether it has not been overrated 
as a remedy for the diathesis itself. Iodine employed internally 
is especially serviceable in glandular hyperplasia, and in scrofulous 
thickening and induration of the connective tissue and periosteum. 
In general, it should not be administered to children in its isolated 
state, on account of its irritating properties, but one of its com- 
pounds should be employed. The compounds which are chiefly 
prescribed in the treatment of scrofula are the iodides of starch, iron, 
potassium, and sodium. If, as is frequently the case, the patient is 
pallid, and his appetite poor, the iodide of iron should be preferred ; 
if not in this cachectic state, the iodide of starch. Pharmaceutists 
prepare syrups of both these iodides, so that they can be readily 
administered to the youngest child. The iodide of starch may be 
administered by dropping from one to five drops of the officinal 
tincture of iodine on a little powdered starch, and giving it in 
syrup. These iodides are preferable to the iodides of potassium 
and sodium for internal administration to children, as they are not 
irritating to the mucous membrane, and the iodine is readily set 
free. Prof. Dalton has, indeed, demonstrated that the iodide of 
starch is decomposed in most of the liquids of the body, and the 
iodine liberated. 

In this city a large proportion of the scrofulous children are 
cachectic, and need iron, and the iodide of iron is more frequently 
employed than any other iodine compounds. In the Out-door 
Department at Bellevue it is daily prescribed for the scrofulous 
children, and with the best results. It is taken readily, and for 
a lengthened period without producing gastric symptoms. To a 
child of six months we give at this institution one drop three 
times daily, and to one of two years three drops, with or without 
cod-liver oil. 

The internal use of mercury as an antidote for scrofula is now 
generally discarded. Unless, perhaps, in those cases in which the 
diathesis is immediately dependent on syphilis, its use for this 
purpose, from what we know of its therapeutic effects, would pro- 
bably be more injurious than beneficial. Walnut leaves, employed 
in various ways, either as a decoction, infusion, wine, or extract, 
have been highly extolled for the treatment of scrofula, but their 
use has not met with favor in the profession, and comparatively 
few can speak from their own observations of their effect. 



120 SCEOFULA. 

Among the medicines which have "been from time to time em- 
ployed for the cure of scrofula, some of which have had consider- 
able reputation, hut which have nearly fallen into disuse, may be 
mentioned sarsaparilla, elecampane, conium, digitalis, horseradish, 
and certain compounds of silver, gold, arsenic, baryta, and bro- 
mine. From what we know of the nature of scrofula, it is proba- 
ble that none of these has any effect upon the diathesis or upon 
scrofulous ailments, except such as improve the appetite and general 
health, like horseradish. The same hygienic measures are required 
in the treatment of scrofula as are demanded in the prophylaxis 
of it. 

The scrofulous affections require additional and special treatment. 
It would transcend the proposed limits of this paper to speak of 
the various measures, medicinal, mechanical, etc., which are de- 
manded for their cure. I shall only describe the treatment of the 
affection, which is especially characteristic of scrofula, namely, 
glandular hyperplasia. 

It is the common practice to treat these glands, if they are sub- 
cutaneous, by daily application over them of the officinal tincture, 
the compound tincture, or the compound ointment of iodine. It 
is my opinion, from observing the effects of these agents, that they 
are too irritating for ordinary cases. Applied daily, they cause 
proliferation of the cells of the epidermis, so that in two or three 
days the thickening of the cuticle is greatly increased, and its ex- 
ternal layer begins to exfoliate. It has appeared to me that what 
we observe in the epidermis illustrates, to a certain extent, what 
occurs in the gland underneath, as a result of active counter-irri- 
tation. The gland does not resolve, its superfluous cells are not 
destroyed and absorbed, as was desired, but the treatment tends 
rather to increase the proliferation of the cells of the gland, or the 
formation in it of true leucocytes. We have seen that a local cuta- 
neous inflammation, as eczema or impetigo, is apt to cause the 
neighboring lymphatic glands to enlarge. How, therefore, can 
we expect to reduce a glandular swelling by a mode of treatment 
which establishes a similar condition. I once produced, partly by 
accident, such an amount of vesication over an enlarged, hard, 
and apparently somewhat indolent gland, in an infant of fourteen 
months, that for a week I was very anxious lest a sore would 
result, which would heal with difficulty, or leave a permanent 
cicatrix, and yet, instead of dispersion of the glandular swelling, 
the pathological processes were so promoted that suppuration and 
discharge of pus occurred by the time that the cuticle had re- 



TREATMENT. 121 

formed. If hyperplasia of the lymphatic glands could be cured 
by counter-irritation, it should have been in this case. 

The correct mode of treating: these glands, therefore, as regards 
external measures, I hold to be, to apply the iodine preparations in 
such a manner that the largest amount of iodine will reach the 
glands by absorption, with little irritation of the skin. I am not 
prepared to state what is the best formula for the application of 
this agent. During the last few months, we have been attempting 
to determine this in the children's class at the Out-door Depart- 
ment at Bellevue, but our statistics of cases are not at present suf- 
ficiently complete or numerous to enable me to make a positive 
statement. I feel justified, however, from the observations already 
made, in recommending the following formulae, as preferable to the 
officinal preparations which are commonly employed: — 

1st. R. Potas. iodidi 5j ; 

Ung. stranionii %]. Misce. 

To be rubbed over the gland several times daily. It should not be 
applied as a plaster, as it is too irritating and will vesicate. I have 
known a glandular swelling, which had continued about three 
months, to disappear in as many weeks, under its use in connection 
with internal remedies. Glycerine may be employed in place of 
stramonium ointment. It makes a nicer preparation. 

2d. R. Liq. iodinii compositi, 
Glycerinse, equal parts. 

To be applied three times daily with thorough friction, but less 
frequently if the skin becomes irritated. In place of Lugol's 
solution, tincture of iodine may be employed, with perhaps a little 
larger proportion of glycerine. One of the chief advantages from 
the employment of glycerine with the stronger iodine preparations 
is that it prevents to a great extent the shrivelling and desiccating 
effect on the cuticle, rendering it soft and in a favorable state for 
absorption. 

3d. R. Liquoris iodinii compositi §ss ; 
A quae ^xv. Misce. 

To be kept constantly upon the skin over the gland by lint soaked 
with it, over which oil-silk may be applied to prevent evaporation. 
4th. In the Medical Press and Circular of August 3d, 1870, J. 
Waring Curran states that he has used with great success what he 
designates a new iodine paint, consisting of half an ounce of iodine, 
the same quantity of iodide of ammonium, 20 ounces of rectified 
spirits, and 4 ounces of glycerine. I have never employed it, but 



122 TUBERCULOSIS. 

presume from its composition that it is useful. If too irritating, 
it can, of course, be diluted. 

Mercurial ointments have been recommended by writers of repu- 
tation for the treatment of these glands. I have employed them, 
and known them to be employed, but cannot say that I have ever 
observed any benefit from their use whatever. In the children's 
class at the Out-door Department at Bellevue we have discarded 
them entirely for this purpose, although both the citrine and white 
precipitate ointments, diluted with an equal quantity of lard, have 
been used with great apparent benefit for chronic coryza -of a 
strumous nature, and also occasionally for external otitis of the 
same nature. 

In a paper read at the meeting. of the British Medical Associa- 
tion in 1870, by Mr. Jordan, the writer recommends, as attended 
with success, vesication, not over the gland, but at a little distance 
from it, as, for example, behind the neck, for treatment of the cer- 
vical glands. But a mode of treatment which seems so unlikely to 
be beneficial requires stronger proof of its utility than has yet been 
presented. 

When the gland becomes actively inflamed, as indicated by in- 
creased heat and tenderness, and redness of the skin, applications 
of iodine are no longer proper. They increase the local disease. 
There is no longer any probability of resolution of the glands, and 
poultices should be applied. 



CHAPTER III. 

TUBEECULOSIS. 

Tuberculosis occurs at any period of life. It is, indeed, more 
frequent in early manhood than previously ; but it presents pecu- 
liar features in children, and especially in infants. Like most other 
general diseases, tuberculosis has a local manifestation which serves 
for diagnosis. This is a small, round, nearly transparent granula- 
tion, designated tubercle, which is developed within a tissue, or 
upon its surface. In certain situations it departs from its typical 
rounded form, and is more or less flattened. It is firm to the feel, 
and, when fully developed, varies in size from a pin's head to a 
small pea. It has recently, in its various phases, been studied with 



TUBERCULOSIS. 123 

great interest by pathologists in Europe, and to a certain extent in 
this county, and these investigations have already thrown con- 
siderable additional light on the nature of tuberculosis. 

The statistics of tuberculosis, previously to the last ten years, 
were not strictly accurate, since cheesy degeneration, of whatever 
part, was regarded by most pathologists as always a tubercular 
lesion, and its presence in the cadaver was therefore considered 
sufficient proof that the disease of which the patient died was 
tuberculosis, whereas it is now known to be, in many instances, a 
degenerated product of simple inflammation. I have records of 
the histories and -post-mortem examinations of thirty-six cases of 
tuberculosis occurring under the age of five years, having rejected 
all cases of cheesy degeneration when not accompanied by other 
evidence of tuberculosis. Thus caries of the vertebrae, with cheesy 
substance in the bony excavations, I have not considered tubercu- 
lar. I have rejected one case in which three large cheesy bronchial 
glands lay in front of the carious vertebrae, inasmuch as there were 
no tubercles in the lungs or elsewhere. In another rejected case, 
the only lesions were empyema of the left pleural cavity, hyper- 
plasia, and cheesy degeneration of the bronchial glands, and a single 
large cheesy nodule in the right lung. 

Etiology. — The tubercular diathesis may be inherited. Hence 
the well-known fact of tubercular families. Cases are not infre- 
quent in which hereditary tuberculosis proves fatal before the 
death of the affected parent. The offspring of a tubercular parent 
does not, as a rule, have tubercles at birth ; but the tubercular dia- 
thesis, at first latent as in syphilis, manifests itself in a few weeks 
or months in the formation of tubercles, and in the consequent 
cough and emaciation. In two cases, however, in my collection, a 
cough was observed, according to the statement of friends, as early 
as the second or third week. Under good hygienic conditions, the 
inherited diathesis may remain latent or be removed. If both 
parents are tubercular, the offspring almost necessarily becomes so. 

Tuberculosis frequently results from prolonged anti-hygienic 
conditions in those previously healthy and of healthy parentage. 
It may result from residence in damp, dark, and dirty apartments, 
from scanty or unwholesome food, protracted and exhausting dis- 
eases, in fine, from any agency which gives rise to great and con- 
tinued impoverishment of the blood. Age is a predisposing cause. 
Tuberculosis is comparatively rare under the age of one year, while 
it is not uncommon in wasted infants between the a^es of two and 
five years. This remark is fully substantiated by the statistics of 



124 TTJBEKCULOSIS. 

the Nursery and Child's Hospital and Infant's Hospital of this 
city. 

Is tuberculosis propagated by infection? Most physicians would 
answer in the negative, though in some countries, as in Italy, it 
is stated that the profession have long regarded it as mildly infec- 
tious. Every physician of experience must have remarked the 
frequency with which tuberculosis occurs in those not predisposed 
to the disease, but who have been in intimate relation with con- 
sumptive patients. This has been commonly regarded as due in 
no way to infection, but has been thought to be a coincidence, or 
has been attributed to an influence not fully understood, which the 
emotions or imagination exerts in the causation of diseases. But 
recent discoveries concerning the etiology of tuberculosis, which 
will presently be related, afford ground for the opinion which some 
of our best authorities in the pathology of tuberculosis, as Wal- 
denburg, now hold, that minute particles exhaled or expectorated 
from the lungs may be the medium of infection. 

In December, 1865, M. Villemin read before the Academy of 
Medicine of Paris and published his celebrated memoir, which 
contained the results of his , experiments in inoculating certain 
lower animals with tubercular matter. Since then the fact has 
been established by many experiments, that tubercle may be pro- 
duced in the rabbit and other animals by inserting under their skin 
various pathological products, whether tubercular or non-tubercu- 
lar, as gray tubercles, cheesy products, thickened pus, etc., and by 
inserting finely divided foreign substances, not animal, as aniline 
blue, and also by traumatic irritations which give rise to the for- 
mation of inflammatory products under the skin, as the use of a 
seton. The coloring matter, whether introduced alone or in com- 
bination with a pathological substance, is found in the tubercle 
which results in the lungs or elsewhere. Therefore it is inferred 
that tubercle in these experimental cases is produced by minute 
particles of the inserted substance, which enter the circulation and 
are deposited in the lungs or other organs. "Where they are de- 
posited, inflammation (formative irritation) occurs, with prolifera- 
tion of the cellular elements of the part. This corpusculation 
produces the tubercle. 

The importance of these discoveries is apparent. Cheesy sub- 
stances produced in the system, whether in the lungs, lymphatic 
glands, bones — as in vertebral caries — or elsewhere, and also long- 
retained purulent collections, as in empyema, may give rise to 



ETIOLOGY. 125 

tuberculosis, provided particles of the morbid substance gain ad- 
mittance into the circulation. 

Blood extra vasated in the alveoli of the lungs, and undergoing 
degenerative changes, is considered a cause of tuberculosis ; but 
such extravasations are rare prior to the age of puberty. Protracted 
inflammation of the air-passages, as bronchitis or laryngitis, is 
stated to give rise to tubercles in certain cases, but it is not easy to 
see how this could occur except when the inflammation has ex- 
tended to the lungs or given rise to cheesy degeneration of the con- 
tiguous glands. In infancy and childhood the common cause is a 
diathesis inherited, or acquired through impoverishment of the 
blood by previous disease or anti-hygienic conditions, or it is in- 
fection of the system from cheesy glands or purulent collections. 

Post-mortem examinations in connection with these recent- dis- 
coveries demonstrate that the immediate cause of the formation of 
tubercles in the lungs, spleen, and other viscera, in certain cases, is 
hyperplasia and cheesy degeneration of the bronchial and mesen- 
teric glands, whether or not this glandular affection is to be con- 
sidered tubercular. Thus in the last two cases which I have ex- 
amined there were minute transparent tubercles in the lungs, some 
becoming yellow, evidently of very recent formation, and also in 
one of the cases in the spleen, while in both cases the bronchial 
glands were enlarged and cheesy, and in one also the mesenteric. 
In another case, occurring in the Child's Hospital, the bronchial 
and mesenteric glands were cheesy, with all the thoracic and ab- 
dominal viscera healthy, while there were granulations nearly the 
size of a pin's head, due to cell proliferation, as ascertained by the 
microscope (tubercular), in the pia mater at the base of the brain, 
along its sides, and between the hemispheres. 

Cases are less frequent, but are occasionally met, in which re- 
tained purulent collections appear to be the cause of the formation 
of tubercles. Thus, in 1870, 1 presented to the New York Patho- 
logical Society the lungs, containing minute, recent tubercles, re- 
moved from an infant, who had died when a few months old. The 
lungs were otherwise healthy, and there were no cheesy glands, for 
which a careful examination was instituted ; but in the left thigh 
was a large deep-seated abscess, which had been detected a month 
before death. 

Another, and probably the most frequent local cause of tubercu- 
losis, is cheesy pneumonia. Caseous degeneration of the inflam- 
matory products is common in young and feeble infants affected 
with pulmonary inflammation, and the supposition is reasonable 



126 TUBERCULOSIS. 

that particles are more readily detached from a caseous mass in the 
lungs than in most other situations. Certainly, in this city, cases 
are not infrequent of young children presenting the history of 
pneumonia, cheesy degeneration, and finally tubercles, especially 
during epidemics of measles. 

General Anatomical Characters of Tuberculosis. — Analysis 
of the blood of tubercular patients shows an increase in the water, 
albumen, fats, and white corpuscles, and a decrease in the number 
of red corpuscles. The fibrin is slightly diminished, except in 
cases complicated by inflammation, in which it may be in excess. 
The chief interest, however, as regards the anatomical characters 
of tuberculosis, pertains to the tubercle. The tubercle is as cha- 
racteristic of tuberculosis as the eruption is of an exanthematic 
fever. It is produced, as already stated, by a local proliferation or 
corpusculation. It is, therefore, a cell-growth, and not a deposit. 

If we examine with a microscope a thin section of a recent 
tubercle, we will observe in its peripheral portion, in which pro- 
liferation was active at the time of death, large mother cells, spin- 
dle-shaped fibro-plastic cells, and small round cells, which have 
been released from the mother cells. This zone of proliferation 
often has considerable extent. Passing towards the central portion 
of the tubercle, we find these small round cells in great abundance. 
They represent a more advanced stage of the tubercle, since the 
central part is oldest. They are the most numerous cells in the 
tubercle, and they have been designated the tubercle cells. They 
resemble closely in appearance the smaller of the white corpuscles 
of the blood, and cannot be distinguished from the normal cells of 
the lymphatic glands, each consisting of a single large nucleus 
surrounded by protoplasm. They are among the most fragile of 
pathological cells. The cells are held together by a transparent 
adhesive substance, which is firm and resisting. 

Every tubercle tends to undergo a molecular change by which 
its transparence is lost. This consists in a decay of the cells and 
the intercellular substance. Granules of fat are deposited within 
them, and the cells shrivel and disintegrate. Fragments of cells, 
and shrunken cells, and cell-nuclei, are thus produced, which Lebert 
described as the tubercle cells, and which were accepted as such by 
all observers till Virchow ascertained their true character. The 
molecular change which I have described commences in the interior 
of the tubercle, and extends outward till the whole tubercle becomes 
opaque and yellow, and at the same time so friable as to be readily 



ANATOMICAL CHARACTERS. 127 

crushed between the fingers. The yellow tubercle is therefore only 
an advanced stage of the gray semi-transparent. 

It is evident that tubercle in its first period possesses vitality, 
and, like all neoplasms, has its bloodvessels. These are soon closed 
by coagula or granular, fibrin, mixed with white blood corpuscles. 
"When the tubercle has reached the yellow transformation, its 
vessels are no longer pervious, but it is surrounded by a vascular 
zone, in which circulation continues. The subsequent history of 
tubercle is well known. It is seldom, perhaps never, absorbed. 
It softens, and henceforth, as has been said by a German patholo- 
gist, its history is that of an abscess. It is an irritant, producing 
inflammation in the surrounding tissues, with thickening and 
induration, and abundant production of pus cells, which mingle 
with the tubercle elements. Ulceration and discharge of the li- 
quefied substance upon one of the free surfaces is the common 
result. In exceptional cases, instead of softening, the tubercle may 
undergo fibroid degeneration or cretification. 

Anatomical Characters in Infancy and Childhood. — The ana- 
tomical characters of tuberculosis in the first years of life vary in 
certain particulars from the form which they present in the adult, 
but after the age of three years the differences are fewer and less 
pronounced than previously. 

Tubercular laryngitis, so common in the adult, is absent in a 
large proportion of cases under the age of three years, and when 
present has little intensity; and ulceration of the larynx very 
seldom occurs. This has been attributed to the fact that there is 
so little expectoration in young children, the sputum being an 
irritant. ]ftlemeyer, however, does not consider the sputum of 
tuberculosis sufficiently irritating to cause laryngitis and laryn- 
geal ulceration; but the arguments in favor of this mode of causa- 
tion, in my opinion, more than counterbalance those which have 
been presented against it. 

I have never met a case of tubercular ulceration of the larynx 
or trachea in the post-mortem examination of young children, nor 
do I recollect ever treating a case in which there was that degree 
of dysphonia which indicated ulceration. Rilliet and Barthez, in 
more than 300 necropsies of tubercular cases, found no ulcers in the 
larynx or trachea under the age of three years ; 8 cases between the 
ages of three and ten years, and 8 between ten and fourteen years. 
The ulcers, whether seated in the larynx or in the trachea — and 
they are in most cases in the former, since the inequalities upon 
the surface of the larynx favor the retention of the sputum — are 



128 TUBERCULOSIS. 

commonly small, superficial, round or elongated, and with little 
thickening or inflammation of their borders. Occurring in the 
folds of the mucous membrane, for example, around the vocal 
cords, their form is usually elongated. 

Bronchitis is not infrequent. This inflammation is due to, and 
dependent on, the pulmonary tubercles, and is therefore most in- 
tense in the part of the lung where the tubercles are most abundant 
and furthest advanced. Consequently it is more intense on one 
side than on the other, and it may be unilateral. It differs in 
this respect from idiopathic bronchitis, which is commonly pretty 
uniform on the two sides. It differs also in the fact that it is 
sometimes accompanied by ulcerations. The ulcers are round or 
elongated in the direction of the axis of the tubes, and, like those 
of the larynx or trachea, are superficial. Idiopathic bronchitis of 
infancy and childhood does not cause ulceration. Circumscribed 
inflammation may attack a bronchial tube, as, indeed, the trachea, 
and gives rise to ulceration and perforation, from the presence and 
pressure of a diseased lymphatic gland external to the tube. This 
subject will be treated of hereafter. 

Lungs. — It is well known that in the adult tubercles are always 
present in the lungs, if they occur in any part of the system. I 
have met two cases in which the lungs were free from tubercles in 
36 post-mortem examinations of children who died of tuberculosis. 
One of the two was an infant, but its exact age is not stated in the 
records. It had cheesy degeneration of thymus and bronchial 
glands, enlargement of mesenteric glands, but without cheesy de- 
generation, and disseminated tubercles in liver and spleen. The 
other, fifteen months old at death, had tubercular meningitis, with 
numerous granulations upon the convexity of the brain, and the 
other usual lesions of meningeal inflammation, with bronchial and 
mesenteric glands slightly enlarged and cheesy, and one of the 
former softened. In one case, then, in 18, the lungs had escaped 
the disease. Rilliet and Barthez state that they found the lungs 
non -tubercular in 47 cases in 312, and Hillier did in 25 cases in 160. 
In their cases, therefore, the lungs were exempt from tubercles in 
about 1 case in 7. But it is to be recollected that the statistics of 
these observers were prepared at the time when all cheesy degene- 
rations were thought to be tubercular, and the bronchial and 
mesenteric glands are sometimes cheesy when there are no tuber- 
cles or lesions referable to tuberculosis in any other part of the 
system. I have records of two such eases, which I reject from my 
statistics of tuberculosis, as there is no evidence that the disease 



LUNGS. 129 

was anything else than simple inflammation. Did I include these 
cases, my statistics would correspond with theirs. 

Pulmonary tubercles in children under the age of three years 
are, as a rule, discrete, and disseminated through the lungs. In 
cases at this age, which have advanced to a fatal termination, we 
commonly find yellow tubercles from the size of a pin's head to a 
shot in the different lobes, many still semi-transparent if the dis- 
ease has been of short duration, but if protracted most of them 
yellow, and here and there one softened and surrounded by con- 
densed fibrous tissue. Around the semi-transparent or gray tuber- 
cles, many of which were growing, and therefore were in the state 
of active cell proliferation at the time of death, narrow vascular 
zones can often be detected by the naked eye. 

Under the age of three years, tuberculosis exhibits but little 
tendency, perhaps none, to afreet the upper lobes sooner or in 
greater degree than the lower. 

The following are the statistics relating to the site of the tuber- 
cles in the lungs in the cases which I have examined. All, it is 
to be remembered, were under the age of three years : — 

Cases. 

Tubercles disseminated throughout the lungs . . .26 

Tubercles disseminated throughout the two upper lobes . 3 
Tubercles disseminated through right middle lobe and left 

lower lobe only 1 

Tubercles disseminated through left upper lobe only . . 2 
Tubercles disseminated (few and semi-transparent) in left 

rung only 1 

Tubercles disseminated in three points in right, and two in 

left lung 1 

No tubercles in lungs 2 

36 

Between the ages of three and fifteen years, statistics show that 
the upper lobes are more liable to tubercles than the lower ; but the 
difference in liability is not great. In many cases occurring in 
this period, the different lobes are affected nearly simultaneously, 
and not very infrequently the upper lobe is the last which is in 
volved. In October, 1866, I made the post-mortem examination of 
a boy who died in the Children's Service of Charity Hospital, at 
the age of fifteen years, and small scattered tubercles were found 
in the lower lobe of the left lung, while all other portions of these 
organs were healthy. Eilliet and Barthez, who include in the 
same statistics all cases from birth to the age of fifteen years, found 
gray semi-transparent tubercles 
9 



130 TUBERCULOSIS. 

Cases. 

In the right superior lobe in 63 

In the right middle lobe in 43 

In the right lower lobe in 55 

In the left superior lobe in 65 

In the left inferior lobe in 54 

The same observers found yellow tubercles in the 

Right superior lobe in . . . . . . . 40 

Right middle lobe in 28 

Right inferior lobe in 39 

Left superior lobe in 35 

Left inferior lobe in 31 

It has already been stated that tubercle originates in a circum- 
scribed inflammation. On the other hand, tubercle, especially when 
softening commences, is itself an irritant, exciting inflammation 
around it. Inflammation occurring from this cause is obviously 
likely to be protracted, continuing for weeks or months, unless the 
tubercular matter is eliminated by ulceration. The highly vascu- 
lar and delicate lungs of the young child are very liable to inflam- 
mation when they are the seat of tubercles, and as the tubercles 
are disseminated, the pneumonia is commonly more extensive than 
when it occurs from ordinary causes. In fifteen, or nearly one- 
half of the cases, there was pneumonia affecting portions of one or 
more lobes, or an entire lobe. From the extent and position of the 
solidified portions, it was obvious that in most cases the inflamma- 
tion originated from the irritating effect of the tubercular matter, 
while in others it was due to hypostatic congestion, occurring in 
consequence of the long-continued recumbent position and the fee- 
bleness of circulation. In these fifteen cases the seat and extent 
of the inflammation were as follows: — 

1 Cases. 

Nearly entire right lung 2 

Nearly entire middle and lower lobe 1 

Entire left upper lobe 2 

A considerable part of both lungs 1 

Posterior parts of both lower lobes 4 

Posterior part of left lung 1 

Left lower lobe, and right middle and lower lobes . . 1 

Left upper lobe (contained a large cavity) and posterior part 

of left lower lobe 1 

Nodules of inflamed lung around tubercles .... 2 

The inflammation in about one-third of the cases was due to hypo- 
stasis, as it occurred in depending portions, extended but little into 
the lungs, and sustained no relation to the amount of tubercle. It 
was in the stage of red, or more rarely of gray, hepatization. 



LUNGS. 131 

In seven of the cases there were pulmonary cavities as large in 
proportion as we ordinarily find in tuberculosis of the adult. The 
seat of one was in the right lower lobe ; of two, the left upper 
lobe ; of one, the right upper lobe ; of another, the right lung, its 
exact seat not stated ; and in the remaining case the cavity, which 
was the largest of all, occupied the interior of all three lobes on the 
right side. Some idea of the size of these cavities may be learned 
by the following extracts from the records. 1st Case. — " A small 
superficial cavity communicating on one side with a bronchial 
tube, and on the other side with a small circumscribed collection 
of pus in the pleural cavity." 2d Case. — " Cavity of the size of a 
hickory-nut." 3d Case. — "Cavity of the size of a large hickory- 
nut." 4th Case. — "Cavity three-fourths of an inch in diameter." 
5th Case. — "A large abscess." 6th Case. — "The cavity occupied 
nearly the whole of the interior of the left upper lobe." 7th Case. — 
" About half the right lung excavated into a cavity which ex- 
tended through the three lobes." 

Circumscribed pleuritis, produced by tubercles underneath the 
pleura, was observed in seven cases. It was ordinarily attended 
by little exudation except the fibrin, but in one case a sufficient 
amount of serum had been exuded to compress considerably the 
lung. Pus was not observed in any notable quantity. 

Emphysema was present in several cases, chiefly in the upper 
lobes, sometimes vesicular, with fulness or bulging of the lung, an 
anaemic appearance of it, and doughy, inelastic feel. In other 
cases emphysema was interstitial, producing little bladders of air 
under the pleura, especially towards the root of the lung, or sepa- 
rating the lobules by wedge-shaped or irregular interspaces filled 
with air. In one case air had escaped from an emphysematous 
bladder into the right pleural cavity, causing pneumothorax and 
collapse of the lung. 

isText to the lungs, the bronchial glands are more frequently dis- 
eased than any other organs, in the tuberculosis of infancy and 
childhood. They undergo the successive structural changes which 
characterize glandular inflammations, namely, hyperplasia, and 
more or fewer of them cheesy degeneration and softening. In the 
state of hyperplasia the firmness is diminished, and they have a 
pale flesh-color. Cheesy degeneration commences in one or more 
points in the gland, sometimes in the peripheral, sometimes in the 
central portion, and it extends till the whole gland presents the 
well-known cheesy appearance. When the gland softens, the thick 
liquid presents a puriform appearance, consisting of amorphous 



132 TUBERCULOSIS. 

matter, fatty particles, and the shrivelled and disintegrated cells 
of the gland. Soon pus cells occur, and their number increases. 

Microscopy shows no anatomical difference between the hyper- 
plasia or cheesy degeneration of the lymphatic glands occurring 
from inflammation, and that from tubercle ; but since the bronchial 
and mesenteric glands are not often cheesy or greatly hyperplastic 
from simple inflammation, and are commonly not only greatly 
enlarged but cheesy in the tuberculosis of young children, we con- 
clude that the inflammation which gives rise to this hyperplasia 
and degeneration in such cases is of a tubercular character. 

Rilliet and Barthez state that the bronchial glands were tuber- 
cular in 249 cases in children, while the lungs were tubercular in 
265 cases. All cheesy glands, it is to be recollected, they consi- 
dered tubercular. In 4 of the 36 cases which I have examined, no 
record was preserved of the state of- the bronchial glands ; in one 
case there was no perceptible hyperplasia and no cheesy degenera- 
tion; in two there was hyperplasia, but no cheesy degeneration, 
while in the remaining twenty-nine cases there was cheesy degen- 
eration of more or fewer of the enlarged glands, or parts of them, 
with occasional softening. In the fact that the bronchial glands 
are tubercular and enlarged, we have an explanation in part of the 
fact, that the symptoms in the tuberculosis of young children differ 
from those in the adult, since Louis found the bronchial glands 
tubercular in only twenty-eight per cent, of the adult cases of 
tuberculosis which he examined, and Lombard in only nine per 
cent. A gland pressing upon the recurrent laryngeal or pneumo- 
gastric nerve, or the trachea, may give rise to dyspnoea and a cough ; 
or on the descending vena cava or one of the vense innominate, to 
congestion of the brain and meninges, intra-cranial serous effusion, 
and even thrombosis in the cranial sinuses. The fact that a soft- 
ened bronchial gland not infrequently is eliminated from the sys- 
tem, by ulceration, into a bronchial tube or the trachea, is well 
known. In one case which I observed the ulceration had destroyed 
portions of three of the cartilaginous rings of a bronchus, and the 
aperture was plugged by a cheesy fragment of a softened gland 
which protruded. Occasionally, it is stated by authors, the ulcera- 
tion is into one of the large vessels of the mediastinum, or even 
into the oesophagus. 

In no case did I find tubercles in the heart or pericardium, 
though they have been observed in rare instances in the latter. 
The mesenteric glands were enlarged by hyperplasia, and more or 
less cheesy, in 30 cases ; in their normal state, to appearance, in 



ABDOMINAL VISCERA. 133 

two cases, and in the remaining four cases their condition was not 
stated. f In most of the cases the mesenteric glands were smaller 
and less cheesy than the bronchial, but in a few instances they 
were larger than the bronchial and more cheesy. 

It is a noteworthy fact, as bearing on the causative relation of 
these glands to tubercles, that not infrequently the amount of hy- 
perplasia and cheesy degeneration of the former was very consi- 
derable, while the tubercles in the lungs or elsewhere were small, 
even minute, semi-transparent, and evidently of recent formation. 

Abdominal Viscera. — In children, tubercles in the solid organs of 
the abdomen rarely give rise to appreciable symptoms, as they are 
small and disseminated, not impairing materially the function of the 
part in which they are located. On the other hand, peritoneal and 
intestinal tubercles, and the enlarged and cheesy mesenteric glands, 
give rise to symptoms which require description. The most frequent 
seat of peritoneal tubercles is upon the attached surface of the peri- 
toneum, where they are formed from the connective tissue. They 
are distinctly seen through the peritoneum, and cause some pro- 
minence of it. Exceptionally their seat is upon its free surface. 
Every portion of the peritoneum, whether visceral, parietal, or 
omental, is liable to tubercles, but general tuberculization of so 
extensive a surface does not occur in any one case. The tubercles 
are spherical or lenticular, and most of them small. Sometimes 
they are very numerous, but so minute as to be scarcely visible. 
They are gray or yellow, according to the age. Peritoneal tuber- 
cles often produce circumscribed peritonitis, causing adhesion of 
opposite surfaces. The tubercles in themselves cannot be detected 
by palpation ; but masses or plaques composed of tubercles and in- 
flammatory products are sometimes so large that they can be felt 
through the abdominal walls. 

The symptoms of peritoneal tuberculosis are attributable, for the 
most part, to the peritonitis. Among them may be enumerated 
abdominal tenderness or pain, meteorism, ascites — usually slight — 
and derangement of the bowels, commonly diarrhoea. As tuber- 
cles in this situation occur, in most cases, subsequently to tuber- 
cles elsewhere, the symptoms which have been described are asso- 
ciated with and are subordinate to others. 

Stomach and Intestines. — The most common seat of gastrointes- 
tinal tubercles is the small intestine, and more frequently its lower 
portion, near the ileo-coecal valve, than its upper or central. They 
are rare in the duodenum or contiguous part of the jejunum. They 



134 TUBERCULOSIS. 

are developed ordiDarily in the connective tissue, either that lying 
under the mucous or the serous surface. 

Grastro-intestinal tubercles are often accompanied by ulceration 
of the adjacent mucous membrane. But in a certain proportion 
of cases there is probably no causative relation of the tubercles 
to the ulcers, for ulceration of this membrane is not infrequent in 
the tuberculosis of children, when there are no tubercles in the 
walls of the stomach or intestines. The following statistics of 
Eilliet and Barthez, relating to this point, will aid in an under- 
standing of the symptoms: — 

Tubercles in walls of stomach, 7 cases, i with ulcers ' 6 cases ' 

I without " 1 case. 

Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases. 

Tubercles in small intestines, 82 cases, i wifrh ulcers ' 70 cases ' 

(without " 12 " 

Ulcers without tubercles in small intestines, 51 cases. 

Tubercles in large intestine, 15 cases, i with ulcers ' 10 cases ' 

(without " 5 " 

Ulcers in large intestine, without tubercles, 47 cases. 

The ulcers have vascular, thickened, and infiltrated borders. 
Their diameters vary from a line to half an inch or more, and their 
general form is circular, or, if two or more unite, irregular. Tuber- 
cular ulcers of the stomach are mostly in the great curvature, those 
of the small intestines in the ileum and lower part of the jejunum, 
and those of the large intestine in the ccecum. 

The following table exhibits the state of the principal abdominal 
viscera in the 36 cases: — 

Liver. Spleen. Kidneys. 

Tubercular ...... 12 22 1 

Non-tubercular 16 6 21 

Not stated 8 8 14 

Fatty 5 .0 

In no instance did I observe tubercular softening in the abdomi- 
nal organs, and a large proportion of the tubercles in the liver, 
spleen, and kidneys were still in the first stage. In the five cases 
in which the liver was recorded fatty, this state of the organ was 
obvious to the sight, as it is in tuberculosis of the adult. A 
moderate excess of fat in the hepatic cells may have been present 
in some of the other cases, but it was not sufficient to be apprecia- 
ble without the microscope. It is to be remarked that in the five 
cases in which the liver was recorded fatty, this organ contained no 
tubercles. The spleen is seen to have been the most frequent seat 
of tubercles of all the viscera, except the lungs. In fourteen cases 



SYMPTOMS. 135 

the intestines were examined; and in live, tubercles discovered 
developed in the connective tissue. The intestinal tubercles were 
small, and ulceration had occurred of the mucous membrane which 
covered them. 

The brain was examined in fifteen cases. In twelve cases the 
amount of cerebro-spinal fluid varied from 3ss to v, by estimation. 
In two others the records state that there was a considerable amount 
of this fluid, the exact quantity not being given, while in the re- 
maining case congestion of the brain and meninges was noticed, 
but nothing: was recorded in regard to the amount of cerebro- 
spinal liquid. The increase of the cerebro-spinal fluid in tubercu- 
losis is attributable to wasting of the brain, a hydrocephalus ex 
vacuo, and in some cases to passive congestion and serous transuda- 
tion, due to feeble circulation, or obstructed flow from the pressure 
of bronchial glands on the vessels within the thorax, as already 
stated. 

Tubercles were present in the pia mater in three cases: in two 
with fibrinous exudation; in the other without fibrin or other 
evidence of inflammation. 

Symptoms. — The symptoms in tuberculosis of children arise in 
part from the diathesis, and in part from the tubercles. Before 
the period of tubercles, there are signs of failing health, such as 
loss of appetite, flabbiness of the soft parts, or emaciation, lassi- 
tude, and loss of strength. These symptoms continue after the 
formation of tubercles, and increase. 

The features are ordinarily pallid, but during the paroxysms 
of fever, to which tubercular patients are subject, they may be 
flushed. Lividity of the features, due to imperfect decarboniza- 
tion of the blood, occurs, if there are enlarged bronchial glands 
which compress the vessels within the thorax, or if there is ex- 
tensive pulmonary tuberculization, or pulmonary tuberculization, 
whether extensive or not, which is complicated by capillary bron- 
chitis or pneumonia. 

The skin is nearly natural, or it loses its flexibility and softness, 
and becomes dry and rough. In some patients there is, at times, 
general or partial furfuraceous desquamation of the skin, due to 
exaggerated development of the epidermis. Children, like adults, 
notwithstanding the general dryness of the surface, are liable to 
perspirations at night and in sleep. This symptom is less frequent 
at the commencement than at an advanced period, and in acute 
than in chronic cases, in the very young, namely, those under three 
or four months, than in older children. It is more abundant about 



136 TUBERCULOSIS. 

the head and limbs than elsewhere, and is sometimes confined to 
these parts. 

Anasarca is not infrequent. It sometimes arises from obstructed 
circulation, in consequence of compression of the thoracic vessels 
by enlarged lymphatic glands ; in other cases it is due to dimin- 
ished plasticity of the blood, a result of the tubercular cachexia. 
The latter is the more common cause. It is not an important 
symptom, on account of the small amount of serous transudation, 
and the character of the parts in which it occurs. 

Emaciation, already alluded to, is early, constant, and progres- 
sive. Under the age of six or eight months it is less marked than 
in older children, many preserving considerable rotundity of fea- 
tures and form even in advanced tuberculosis. The failure of the 
strength corresponds in amount and progress with the emaciation. 
Slight at first, and exhibited only by a degree of lassitude, it gra- 
dually increases, till for weeks before death the little patient is 
fatigued by the ordinary muscular movements, and is disposed to 
keep quiet. 

The nervous system is not ordinarily affected except in cases of 
intra-cranial tubercles. In acute tuberculosis, or tuberculosis com- 
plicated by severe inflammation, there may be agitation and deli- 
rium, especially at night. 

In most patients the mucous membrane of the buccal cavity 
presents its normal appearance, with the exception of a moist fur 
upon the tongue, and a paler hue than normal of its surface gene- 
rally. In acute tuberculosis, and in cases complicated by inflam- 
mation, the tongue' is sometimes dry and brown. The appetite 
may be normal till the close of life, or it is poor or changeable. 
Occasionally it is increased, although the disease is progressing. 
The bowels are regular or relaxed. Diarrhoea may be a prominent 
symptom, even when there are no intestinal tubercles or ulceration. 
Meteorism and fulness of the abdomen are common. 

Fever, constant, but usually with evening exacerbations, is rarely 
absent. It continues for weeks or months. During the exacerba- 
tion the pulse rises to 120, 140, or even to 180 beats per minute, 
and there is a corresponding exaltation of the temperature, which 
in the latter part of the day, without inflammatory complication, 
ranges from 100° to 102° or 103°. The fever is a symptom of 
diagnostic value as regards the nature of the disease, though it 
does not indicate the seat of the tubercles. 

In addition to the symptoms now described, there are special 
symptoms, due to tuberculization of the different organs. In young 



SYMPTOMS. 137 

children, on account of the fact already referred to, namely, the 
tendency to a generalization of tubercles, there is apt to be a blend- 
ing of the symptoms which arise from different organs, but with 
care it is not difficult in most instances to isolate and refer them 
to their proper source. The following are the symptoms which 
arise from tuberculization of the more important organs. 1st. En- 
cephalon. The symptoms produced by tubercles of the encephalon 
vary according to their seat and size, and the structural changes in 
surrounding parts to which they give rise. Meningeal tubercles, 
which are located for the most part in the meshes of the pia mater, 
and by preference along the course of the small arteries, are ordi- 
narily small, not more than a line in diameter, and they may 
remain latent for a considerable time. In the majority of cases, 
however, they sooner or later cause meningitis, the symptoms of 
which are well known and need not be described. But tubercles 
in this situation do sometimes give rise to symptoms when there is 
no meningeal inflammation. They occasion congestion of the sur- 
rounding vessels, and serous transudation, and if developed on the 
under surface of the pia mater they may produce symptoms by 
encroaching upon and irritating the brain ; for they are sometimes 
so much imbedded in the convolutions that careful examination is 
required in order to determine that they are meningeal, and not 
cerebral. Among these symptoms may be mentioned headache, 
frontal or occipital, sometimes intermittent, nausea, melancholy, 
and in certain cases the symptoms produced by the serous transu- 
dation. 

The symptoms of cerebral are in part similar to those of menin- 
geal tubercles, but in most cases others of a neuropathic character 
are present, which serve for differential diagnosis. The differences 
as regards the symptoms of different patients affected with cerebral 
tubercles are attributable in part to the fact that their size and 
rapidity of growth vary, but more to the difference in their seat; 
for any part of the brain may be the seat of tubercles, though cer- 
tain portions, as the cerebellum, are more frequently affected than 
others. 

The child with cerebral tubercles is quiet, but irritable and easily 
excited. Delirium is not common, but many before the close of 
life exhibit a degree of mental dulness. The headache, common 
in cases of cerebral as well as meningeal tubercles, may be nearly 
general, or it is frontal, parietal, or occipital, according to the seat 
of the tubercles. It is often lancinating, often intermittent. 

Clonic convulsions occur towards the close of life. Exception- 



188 TUBEECULOSIS. 

ally they are among the earliest symptoms. Observations have 
failed to establish any relation between the seat of the tubercles 
and the localization of the convulsions. The convulsions may be 
unilateral, while the tubercles are in both hemispheres ; or general, 
while the tubercles are on one side only. 

The severity and duration of the convulsive attacks, and the 
frequency of their occurrence in tuberculosis of the brain, vary 
greatly in different patients. They have been attributed to soften- 
ing of the cerebral substance, which sometimes occurs immediately 
around the tubercles, to local congestions excited by them, and also 
to serous effusion in the ventricles. The convulsions, sooner or 
later, end in paralysis or coma. 

Contraction, or tonic convulsion of certain muscles, is sometimes 
observed. Its most frequent seat is the muscles of the back, and 
of one or both of the lower extremities. It is a late symptom. It 
occurs in those cases in which there is softening around the tuber- 
cles, and usually in the muscles of the opposite side. 

Paralysis is also a late, but not an unfrequent symptom. It is 
preceded by headache, and sometimes, as already stated, by con- 
vulsions. Occurring as a symptom of tuberculosis of the brain, it 
is due either to pressure on a cranial nerve, or to compression and 
perhaps softening of the cerebral substance. The paralysis may be 
paraplegic, commencing as feebleness of the lower extremities, and 
increasing until it becomes complete, or a more or less complete 
hemiplegia. In paraplegia due to tubercles of the brain, the cere- 
bellum is, as a rule, their seat, while paralysis of one side, or of 
certain muscles of one side, indicates tubercles of the opposite cere- 
bral hemisphere ; but there are exceptions. Paralysis of the third 
cranial nerve gives rise to ptosis, of the sixth to paralysis of the 
external motor nerves of the eye, and therefore to internal stra- 
bismus. 

Feebleness or loss of vision, inequality, oscillation, and finally 
dilatation of the pupils, are not infrequent symptoms of tubercu- 
losis of the brain, and they possess great diagnostic value. Atrophy 
of the optic nerve, causing amaurosis, sometimes results from tuber- 
cles as well as other tumors of the brain. Atrophy of this nerve 
occurs not only when the tubercles are so located as to press on the 
optic tract, in which case the explanation is apparent, but also, in 
certain patients, when the tubercles are in other parts of the brain. 
In these last cases it is thought by Brown-Sequard and others that 
the imperfect nutrition of the nerve is due to contraction of its 
nutrient vessels, produced by the tubercles through reflex action. 



BRONCHIAL GLANDS. 139 

In tuberculosis of the brain, symptoms pertaining to the respira- 
tory, circulatory, and digestive systems are either absent or are 
quite subordinate to those of a neuropathic character. Slowness 
of the pulse, with or without intermitteuce, has sometimes been 
observed, and it is therefore a symptom of some diagnostic value. 
Towards the close of life both pulse and respiration are apt to be 
accelerated. Vomiting, constipation, and retraction of the abdo- 
men, which are so common in meningitis, are only occasional 
symptoms. 

Bronchial Glands. — During the progress of tuberculosis, hyper- 
plasia, cheesy degeneration, and softening may occur of various 
lymphatic glands throughout the body, but the bronchial and 
mesenteric are not only those which are most frequently affected, 
but they are the only glands, unless in exceptional instances, which 
materially increase the danger or give rise to special symptoms. 
These symptoms either have a mechanical cause, namely, the pres- 
sure exerted by the enlarged glands on contiguous parts, or they 
are due to softening of the glands and consecutive, inflammation 
and ulceration. 

The following are the principal symptoms due to compression. 
Some of them are not infrequent; others are rare. Compression 
of the pulmonary veins retards the flow of blood from the lungs to 
the left auricle, giving rise to congestion, and, in extreme cases, 
oedema of the lungs, with sanguineous extravasations into the lung 
substance, congestion of the right cavities of the heart, hepatic 
veins, and of the systemic capillaries generally. Compression of 
the pneumogastric nerve, or of the recurrent laryngeal, which is 
the motor nerve of the laryngeal muscles, produces a cough which 
is apt to be spasmodic, and modifies the voice. The cough resem- 
bles that of pertussis, and has been mistaken for it, but it is not so 
violent or protracted. The voice, clear and natural at first, becomes 
by degrees hoarse or feeble from deficient innervation of the laryn- 
geal muscles. 

An enlarged gland, or mass of glands, lying against the trachea 
or one of the bronchial tubes (this may occur with tubes up to the 
third or fourth division), and pressing its walls inward, obviously 
obstructs more or less the current of air. If there is considerable 
obstruction, a loud sonorous rale is produced, which is heard dis- 
tinctly at a distance from the chest, obscuring other rales. It is 
loudest when the patient is agitated, and it sometimes intermits. 
Feeble respiratory murmur, dyspnoea, and a cough are not infre- 
quent in bronchial phthisis. Diminished intensity of the respira- 



140 TUBEKCULOSIS. 

tory murmur is general or partial, according to the seat of the com- 
pression. It has been most frequently observed at the summit of 
the lungs. In certain patients this symptom is not constant, the 
respiration being for a time feeble and then normal. The dyspnoea 
may be a prominent and distressing symptom, the alae nasi dilating, 
and the infra-mammary region sinking with each inspiration. The 
cough which occurs when a gland presses on the trachea or bron- 
chial tube, is due to the tracheitis or bronchitis to which the pres- 
sure gives rise. If ulceration occur at the point of pressure, the 
cough continues as long as the ulcer remains. Compression of the 
large veins within the thorax, which return blood from the head 
and upper extremities, causes more or less congestion of these parts, 
with, perhaps, transudation of serum in the subcutaneous cellular 
tissue, and within the cranium. Rarely a softened gland by ulcera- 
tion gives rise to other symptoms than those mentioned, namely, 
hemorrhage by ulceration into a vessel, or pleuritis or pneumonitis 
if the ulceration is towards the lungs. 

Improvement in the condition of the patient affected with bron- 
chial phthisis is not unusual. It may be permanent, but in most 
patients it is temporary, so that in a few weeks or months the 
symptoms are as severe as before. The improvement is due to soft- 
ening and elimination of a gland which had given rise to symp- 
toms by its mechanical effect, or by the inflammation which it had 
excited. 

Physical Signs. — These are absent or obscure in the incipient 
disease, when the glands are small, and they are most marked in 
those cases in which the glands are so large as to press on the 
thoracic walls, since the glands then become the medium for the 
transmission of sounds to the ear. The part of the thorax against 
which they most frequently press is the dorsal vertebras, from the 
first to the sixth, and each side of the vertebrae, and less frequently 
the upper third of the sternum. The physical signs are dulness on 
percussion over the interscapular space, and perhaps, though to a less 
extent, over the upper part of the sternum, and bronchial respira- 
tion in the same situations. Occasionally a bruit can be detected, 
due to the pressure of a gland on one of the large vessels of the 
chest. 

Lungs. — A cough is one of the earliest and most persistent of 
the symptoms of pulmonary tuberculosis. It is so rarely absent, 
that those of largest experience do not meet with more than one 
or two such cases. It Varies in severity and frequency. If the 
tuberculosis is acute and its course rapid, the cough, even from its 



PHYSICAL SIGNS. 141 

commencement, is frequent, so as to weary the patient and deprive 
him of needed rest. But in ordinary cases, namely, when the dis- 
ease is chronic, the cough commences gradually, attracting little 
attention by its infrequency, but becoming more frequent and 
painful as the disease advances. 

Ordinarily the cough is dry in the first weeks or months, but it 
becomes looser in the course of the disease, from the greater amount 
of bronchial inflammation. In exceptional instances the cough 
has a spasmodic character, like that produced by pressure of an 
enlarged bronchial gland on the pneumogastric or recurrent laryn- 
geal nerve. This occurs from the accumulation of viscid mucus 
in one or more of the bronchial tubes, usually in dilated portions 
of them, from which it is with difficulty expectorated. 

The respiration in pulmonary tuberculosis is accelerated in pro- 
portion to the degree of tuberculization. Tuberculization of a 
considerable part of both lungs gives rise to dyspnoea, especially 
when, as is ordinarily the case, bronchial, pulmonary, or pleuritic 
inflammation has supervened. Pneumonitis or pleuritis gives rise 
to the expiratory moan, and as these inflammations, when induced 
by tubercles, are protracted, this symptom may continue for weeks 
or months. 

Patients under the age of six years do not expectorate, or but 
rarely. After this age expectoration is not common in the com- 
mencement of pulmonary tuberculosis, but in the confirmed disease 
it is a pretty constant attendant of the cough. Haemoptysis is also 
rare under the age of six years, and less frequent subsequently than 
in the adult. It is most apt to occur in those cases in which there 
is already passive congestion of the lungs, produced by the pressure 
of enlarged bronchial glands in the manner already described. 
Patients old enough to make known the subjective symptoms, 
sometimes complain of fugitive pains under the sternum or between 
the shoulders. 

Physical Signs. — In young children the physical signs of in- 
cipient pulmonary tuberculosis are wanting, or are so obscure as 
not to be readily recognized. This is due to the small size and 
dissemination of the tubercles. In older children, because, as a 
rule, the tubercles are aggregated, and are more frequently at the 
apices of the lungs than elsewhere, as in the adult, the physical 
signs appear early, and are readily recognized. In the advanced 
disease, whether in infancy or childhood, when inflammation and 
more or less destruction of the lung substance have occurred, the 
physical signs, so far from being obscure, enable us in most cases, 



142 TUBERCULOSIS. 

in connection with the history, to make an immediate and positive 
diagnosis. 

In most children affected with pulmonary tuberculosis the 
irregular and imperfect expansion of the lungs produces by de- 
grees changes in the shape of the thorax, which are apparent 
on inspection. In some, the lungs being habitually imperfectly 
inflated, the obliquity of the ribs is increased, and the thorax 
consequently elongated, while its antero-posterior and transverse 
diameters are diminished. This obviously increases the convexity 
or arch of the diaphragm, so that this muscle sometimes lies against 
the thoracic walls as high as the ninth or even eighth rib. If the 
costal cartilages are yielding, there is anterior flattening of the 
chest and depression of the sternum ; if they are firm, on account 
of the more advanced age, the chest remains circular. 

Another shape of the thorax is not infrequent in feeble tuber- 
cular children, especially infants, who have suffered from repeated 
attacks of bronchitis. It occurs also in the non-tubercular, if the 
conditions which favor it are present. The conditions are, on the 
one hand, feebleness of the patient, with diminished force of respi- 
ration and impaired resiliency of the ribs ; and, on the other, ob- 
struction by mucus of one or more of the bronchial tubes. Occlu- 
sion, more or less complete, of a bronchial tube, and consequent 
obstruction to the current of air, produces a corresponding degree 
of collapse in the portion of lung to which the tube leads. The 
portions which collapse are, in most cases, the lower lobes, and the 
thin anterior margins of the upper lobes. This causes lateral de- 
pression of the lower ribs, except such as are pressed outward by 
the abdominal viscera, and an anterior projection of the lower part 
of the sternum. The shape of the thorax in these cases differs 
from that in rachitis, in the fact that the lateral depression does 
not extend to the upper ribs, nor does the upper part of the sternum 
project. 

Certain precautions should be observed in examining the chest 
by percussion and auscultation. The child should sit or recline, 
with the arms and shoulders in the same position, and the axis of 
the trunk straight. Inclination of the trunk to either side, raising 
or depressing a shoulder, may produce an appreciable difference in 
the two sides as regards the physical signs. Percussion of the two 
sides should be practised at the same stage of respiration. A 
slight difference in the degree of resonance does not afford proof of 
disease, unless it is observed at different examinations; for in feeble 
children it often happens that all portions of the lungs do not ex- 



PLEURA. 143 

panel alike, so that where we have noticed slight dulness at one 
visit, it may by the next have disappeared, or even at the same 
visit if forcible inspirations are excited. 

The physical signs ascertained by palpation, auscultation, and 
percussion are, as in the adult, vocal fremitus, bronchial respiration, 
bronchophony, and dulness on percussion. In those cases in which 
the tubercles are mainly at the apices of the lungs, diminished ex- 
pansion of the infra-clavicular region is observed during inspira- 
tion, and this part of the thoracic wall is permanently depressed, 
so that the clavicles are unusually prominent. If there is emphy- 
sema, this flattening does not occur, or is slight. Dulness on per- 
cussion, though more frequently observed in the infra-clavicular 
region than elsewhere, may be present in different isolated places. 
If pneumonia supervene, the dulness not infrequently extends over 
a considerable part of one lung. The crack-pot sound is often 
observed on percussion, but it possesses no diagnostic value. It 
can be produced, when there is no pulmonary disease, by percussing 
over a bronchus. 

Bronchial respiration and bronchophony are important signs, as 
indicating solidification of the lung, but they do not show whether 
the solidification is tubercular or pneumonic, or the two conjoined. 
This must be determined by the history of the case, the extent of 
surface over which these signs are heard, and their persistence. 
When the tubercles begin to soften, and the lung tissue breaks up, 
moist rales appear, often hoarse and gurgling, obscuring the bron- 
chial respiration. A cavity in the lung, or pneumothorax, is 
attended by the same physical signs as in the adult. 

Pleura. — Little need be said in reference to the symptoms and 
physical signs of tuberculosis of the pleura, since this affection is 
in most instances associated with tuberculosis of the lungs, and is 
not distinguishable from it. But now and then the pleural tuber- 
cles are numerous and large, giving rise to symptoms, while those 
of the lungs are small, few, and without symptoms, or attended by 
symptoms which are quite subordinate. Either the costal or vis- 
ceral portion of the pleura may be the seat of tubercles. They are 
developed directly under the pleura, or upon its free surface. They 
are very apt to occur in the newly-formed connective tissue which 
results from pleuritis. Those located upon the free surface, or 
under the costal pleura, rarely soften, while those under the visceral 
pleura sometimes soften and cause ulceration. Occasionally nu- 
merous aggregated tubercles form a firm continuous layer upon the 
surface of the pleura, preventing, if upon the visceral pleura, full 



144 TUBERCULOSIS. 

expansion of the lung. This may give rise to a degree of dulness 
on percussion, and feebleness of the respiratory murmur. Ordi- 
narily, however, in this form of tuberculosis, the symptoms and 
physical signs, so far as any are observed, are due to the pleuritic 
inflammation which the tubercles excite. 

Stomach and Intestines. — The symptoms in tuberculosis of the 
stomach and intestines vary according, to the seat and stage of the 
tubercles. 

Tubercles, whether gastric or intestinal, are not at first accom- 
panied by symptoms, or the symptoms are obscure and ill-defined. 
Symptoms arise when inflammation occurs in the adjacent tissues. 
Diarrhoea is one of the most common and persistent of the symp- 
toms. The alvine discharges are brown and thin, and sometimes 
in advanced cases very offensive. They may be streaked with 
blood which has escaped from the ulcers. Intestinal tubercles, de- 
veloped immediately underneath the peritoneal coat, sometimes 
cause local peritonitis, usually of little extent. This gives rise to 
circumscribed pain, tenderness, and more or less meteorism. 

Diagnosis. — It is evident from the foregoing description of 
symptoms that the diagnosis of incipient tuberculosis is much 
more difficult in children than adults. Before commencing the 
examination, it is advisable to learn the hereditary tendencies of 
the family and the history of the patient, especially as regards 
antecedent diseases or debilitating agencies, and the duration of 
the symptoms. 

Tuberculosis of the encephalon is diagnosticated with more 
difficulty than that of the thoracic or abdominal organs ; but 
certain of these organs are in most cases tubercular at the same 
time, and the knowledge of the fact that they are affected aids in 
the diagnosis of the disease of the brain or its meninges. Among 
the symptoms which possess diagnostic value may be mentioned 
cephalalgia and more or less fever, with exacerbations in the com- 
mencement of the disease, and at a more advanced period strabis- 
mus, inequality or irregular action of the pupils, impairment of 
vision, retraction of the head, and convulsive movements or 
paralysis. 

In certain cases careful observation and discrimination of symp- 
toms are requisite, in order to determine whether they arise from 
intra-cranial tubercles, or from congestion of the brain caused by 
obstruction in the venous circulation by the pressure of enlarged 
bronchial glands. 

The diagnosis of bronchial phthisis, when the glands are still 



DIAGNOSIS. 145 

small, is necessarily uncertain, on account of the absence of symp- 
toms. When they have increased in size and are so located as to 
press on the pneumogastric or recurrent larjmgeal nerve, producing 
the spasmodic cough already described, the differential diagnosis 
between that disease and pertussis may be made by attention to 
the following facts : Bronchial phthisis occurs singly, and is non- 
contagious, while pertussis occurs as an epidemic, and with evi- 
dences of contagion. There are no successive stages, namely, those 
of catarrh, paroxysmal cough, and decline, as in that disease, and 
the cough, though paroxysmal, is short, and without hoop or 
vomiting. 

In feeble children, with inherited tubercular diathesis, emacia- 
tion, sweats, and a chronic cough, with the absence of pulmonary 
symptoms, should excite suspicions that the bronchial glands are 
involved. The evidence is almost conclusive if the cough becomes 
paroxysmal, and there is a loud, persistent, tracheal, or bronchial 
rale. 

In certain of the patients affected with this form of the disease, 
we have seen that the prominent symptoms are due to compression 
of one or more of the large vessels in the chest. Compression of 
these vessels, and consequent retarded circulation, may be con- 
fidently referred to enlarged bronchial glands, since aneurism, 
carcinomatous or other tumors, which would produce a similar 
result, are very rare before puberty. Sometimes the diagnosis is 
rendered certain by the physical signs observed by auscultation, 
and percussion over the sternum and the interscapular space. The 
condition of the external glands should also be observed, as those 
of the axilla, neck, and groin. 

The diagnosis of pulmonary, though more readily made than 
that of intra-cranial and bronchial tuberculosis, is often difficult 
and uncertain. This is, in part, explained by the fact that the 
tubercles are so frequently disseminated, while emaciation and a 
chronic cough are not infrequent from other causes than tubercles. 
Rachitis, intestinal worms, dentition, simple tracheal or bronchial 
inflammation, may be attended both by a chronic cough and 
emaciation. Caution is therefore requisite in order to avoid a 
grave error in diagnosis. Precipitancy in the diagnosis of doubtful 
cases is worse than indecision, and it is often best to postpone an 
expression of opinion as to the nature of the disease till the case 
has been observed for a few days. 

The significance and importance of the symptoms, physical signs, 
and other facts on which a diagnosis must be based, have already 
10 



146 TUBERCULOSIS. 

been sufficiently pointed out. It is difficult, in fact in certain cases 
impossible, to discriminate between simple cheesy pneumonia and 
cheesy pneumonia which has ended in the formation of tubercles. 
The patient has an attack of catarrhal pneumonia; but, instead of 
absorption of the inflammatory product, cheesy infiltration occurs, 
and the lung in places becomes infiltrated with pus, softens, and 
breaks down. The patient presents the symptoms and physical 
signs of phthisis. He may recover after a protracted sickness, or 
may die. The disease may, and often does, remain a pneumonia ; 
but this is a condition of the lungs which favors the development 
of tubercles, and in a certain proportion of cases tubercles do form 
in the last weeks of life. Though the differential diagnosis in such 
cases between simple pneumonia and tuberculosis supervening on 
pneumonia is impossible, practically the discrimination is unim- 
portant, as the same treatment is required. 

Advanced pulmonary tuberculosis, except when it supervenes 
upon pneumonia, can in most instances be readily diagnosticated 
by a careful examination. Still, it is to be recollected, as already 
pointed out, that certain of the symptoms and physical signs, which 
occurring in the adult would afford almost positive proof of pul- 
monary tuberculosis, in children not infrequently have a different 
origin. 

The diagnosis of tubercles in the abdominal organs is facilitated 
by the presence of symptoms which indicate at the same time 
tuberculosis of the lungs. Among the chief diagnostic signs of 
tuberculosis of the peritoneum may be mentioned meteorism and a 
degree of tenderness on pressure. But there is danger of mistaking 
the tympanitic state of the intestines common in ill-nourished in- 
fants and the rachitic, or the fulness due to enlarged spleen or 
liver, to that occasioned by peritoneal tuberculization, and vice 
versa. The history of the case, and a careful examination of 
accompanying symptoms, and the shape and feel of the abdomen, 
usually suffice to establish the diagnosis. In simple gaseous disten- 
sion of the abdomen there is an absence of the symptoms, general 
and local, which attend tuberculosis; rachitis occurs at an earlier 
age than peritoneal tuberculosis, and digital examination, aided by 
percussion, enables us to diagnosticate enlargement of the liver or 
spleen. 

Tubercular enlargement of the mesenteric glands cannot be 
positively diagnosticated when they are small. When they have 
attained such a size that they can be felt through the abdominal 
walls, palpation in connection with the history and symptoms of tu- 



TREATMENT. 147 

berculosis suffices to establish the diagnosis. The glandular tumors 
can be diagnosticated from other tumors by the fact that they are 
tender on pressure, and occupy the umbilical region, while fecal 
tumors are not tender, and are located in the iliac or lumbar region. 
Gastro-intestinal tuberculosis cannot be positively diagnosticated. 
Protracted diarrhoea, or frequent attacks of diarrhoea, not readily 
controlled by medicine, and occurring in tubercular cases, are 
probably associated with intestinal ulceration ; but in only a certain 
proportion of cases of ulceration are there also tubercles in the walls 
of the intestines. 

Prognosis. — Death is the ordinary result of tuberculosis in the 
child, as it is in the adult; but now and then one recovers. Hos- 
jutal statistics show that the average duration of the disease is 
from three to seven months. Under favorable circumstances it is 
more protracted, even to two or three years. Those succumb 
soonest who inherit a strongly-marked tubercular diathesis, live in 
damp, dark, and ill-ventilated apartments, and whose diet is scanty 
or of poor quality. Therefore in the poor quarters of the city 
tuberculosis presents a worse form and pursues a more rapid course 
than among families in better circumstances. 

Favorable prognostic signs are absence of tubercular diathesis, 
good appetite and general health, with little emaciation, infrequency 
of cough, with respiration, pulse, and temperature nearly normal. 
Such symptoms may afford hope of recovery with judicious regi- 
menal and therapeutic measures. On the other hand, if the symp- 
toms are grave, death is inevitable, unless in bronchial phthisis, in 
which, even when there is considerable urgency of symptoms, the 
offending gland is sometimes eliminated by softening and ulcera- 
tion, and the patient improves temporarily, if he does not ulti- 
mately recover. Complete and permanent recovery is, however, 
quite exceptional. 

Death in tuberculosis of children may occur from exhaustion 
induced by the general disease, or from the local effect of the 
tubercles. Thus, in intra-cranial tuberculosis it may result from 
coma; in pulmonary tuberculosis, from dyspnoea, though more fre- 
quently from exhaustion; in that of the bronchial glands, from 
coma, dyspnoea, exhaustion, or even from hemorrhage ; in that of 
the abdominal organs, from peritonitis or protracted diarrhoea. 

Treatment. Prophylactic. — Though tuberculosis is so obstinate 
and fatal, it is often in our power, if forewarned, to avert it. A 
nursing infant, whose mother has the disease, should be immedi- 
ately taken from the breast and intrusted to a wet-nurse. The 



148 TUBERCULOSIS. 

health of the mother as well as infant requires this. If the father 
has the disease, and the mother's milk is inadequate or of poor 
quality, and the infant is under the age of six months, the same 
change should be made, rather than supply the deficiency by arti- 
ficial feeding. Children who are weaned should have plain but 
nutritious and easily digested diet, a part of which should be milk. 
If the predisposition to tuberculosis is strong, a little alcoholic stim- 
ulant may be allowed three or four times daily in the milk, though 
with the risk of creating an appetite for it. To an infant two or 
three drops of Bourbon whisky may be given for each month of 
its age, and to children of three to five years a teaspoonful. Resi- 
dence in an airy and salubrious locality, out-door exercise, a scru- 
pulous avoidance of exposure by which a cold might be contracted, 
are necessary in order to the continued latency of the diathesis. 
Loss of flesh or appetite, or other evidences of failing health, indi- 
cate the need of additional measures of a therapeutic character. 
Iron, with cod-liver oil, citrate of iron and quinine, elixir of cal- 
isaya bark, or other tonic, should be employed in connection with 
the alcoholic stimulant and suitable regimen. By the employment 
of such precautionary measures as soon as indicated, multitudes of 
children might be saved from this disease who now perish. 

Curative. — The treatment of the general disease should be the 
same in children as in adults. The medicinal curative agents 
which are required in ordinary cases are cod-liver oil, iron, or other 
tonic, and an alcoholic stimulant given three or four times daily. 
The oil is less unpleasant and more readily taken when combined 
with the stimulant. An eligible mixture is equal parts of cod- 
liver oil and wine of iron, or cod-liver oil with half its quantity of 
Bourbon whisky, and a few drops of the tincture of chloride of 
iron. It should be given after nursing or the meals. At the age 
of one year two drops of the tincture of iron and a teaspoonful of 
cod-liver oil would constitute an ordinary dose. 

If the cod-liver oil is not tolerated, or if it impairs the appe- 
tite, it should be discontinued. In cases of diarrhoea it is of little 
or no benefit, and may do harm. Under such circumstances pa- 
tients sometimes do better with simple regimenal measures, aided 
by alcoholic stimulants, and one of the least unpleasant of the 
tonics, as wine of iron or the calisaya bark. The regimen already 
recommended for prevention, is also required as a part of the cura- 
tive treatment. 

Certain modifications of treatment are demanded on account of 
the localization of the tubercles. Intra-cranial tuberculosis, as soon 



SYPHILIS. 149 

as diagnosticated, should be treated by pretty decided doses of 
iodide of potassium, though, unfortunately, there is little prospect 
of improvement. The glandular disease, whether bronchial or 
mesenteric, requires the iodide of iron, with or without that of 
potassium. Pneumonitis or pleuritis, so frequent a complication 
of pulmonary tuberculosis, requires emollient poultices, with mode- 
rate counter-irritation, and the judicious use of opiates with stim- 
ulants. The peritonitis occurring in abdominal tuberculosis, which 
is usually circumscribed, is best treated by fomentations and poul- 
tices, with opiates, and the diarrhoea by subnitrate of bismuth and 
chalk, five to ten grains of each, or the bismuth with Dover's 
powder: or a more active astringent. 



CHAPTER IV. 
SYPHILIS. 

Syphilis in infancy and childhood presents itself under two forms, 
namely, the congenital and acquired; the former is the more fre- 
quent. 

Etiology. — Congenital syphilis may be derived from either father 
or mother. Either parent, having previously had syphilis, may 
transmit it to ; the offspring, although at the time free from syphi- 
litic symptoms. The mother, healthy at the time of conception, 
but infected with syphilis prior to the eighth month of gestation, 
may communicate the disease to the foetus ; syphilis contracted in 
the eighth or ninth month does not affect the foetus. If both pa- 
rents have syphilis, the infant is almost necessarily syphilitic; on 
the other hand, if only one parent is affected, the infant may or 
may not be contaminated. Sometimes, with such parentage, a 
part of the children are syphilitic, and a part healthy. 

Acquired syphilis in infancy and childhood may be received 
through primary lesions — that is, by reception of the virus from a 
chancre or bubo ; or it may be derived from certain of the secondary 
lesions. Inoculation by primary lesions may occur at the birth of 
the infant, from a syphilitic sore in the vagina or upon the vulva 
of the mother; inoculation in this manner is, however, rare. Chil- 
dren may also receive the virus from primary lesions on the persons 
of nurses or companions. Infection in this manner is sometimes 



150 SYPHILIS. 

accidental, and sometimes the result of criminal conduct. A chancre 
on the breast of the wet-nurse not very infrequently communicates 
syphilis to the nursling. 

The contagiousness of " secondary manifestations," for a long 
time doubted, is now fully established. Syphilis may be communi- 
cated by the secretion or exudation of a mucous patch, or a second- 
ary sore. Hence the danger of lactation by unhealthy wet-nurses, 
though they present no symptoms of recent syphilis. Excoriations 
or sores upon the nipple or breast of an infected wet-nurse may 
communicate the disease to the nursling ; and, on the other hand, 
mucous tubercles or fissures upon the lips or tongue of the infected 
infant may be the means of contaminating a healthy wet-nurse. 
Many such cases are now contained in the records of medicine. 
Vaccination by means of the scab is also a mode by which consti- 
tutional syphilis may be communicated. For further particulars in 
reference to this subject the reader is referred to our remarks on 
vaccination. 

Clinical History. — Syphilis occurring in the foetus often destroys 
its life and produces miscarriage. The foetus has a shrivelled and 
diseased appearance, its skin peels, the liver is occasionally indu- 
rated, and abscesses with spots of inflammation are sometimes ob- 
served in the thymus gland. So frequently is syphilis a cause of 
non-viability, that, as Trousseau has remarked, this disease should 
be suspected as the cause whenever a woman repeatedly aborts. 
Abortion from syphilis commonly occurs at or about the sixth 
month of gestation. 

The viable infant, affected with syphilis, ordinarily presents, at 
birth, no symptoms or appearances which indicate the nature of the 
disease with which it is contaminated. But there are exceptions. 
Recently I was enabled to diagnosticate syphilis in an infant within 
a day after birth, by its small size and feebleness, and the appear- 
ance of large blebs of pemphigus upon the hands and feet, fingers 
and toes, over which the skin soon broke, leaving troublesome and 
bleeding sores; coryza commenced about the twelfth day. The 
parents of this child appeared healthy, but I could finally trace the 
syphilitic taint to the mother. Well-marked pemphigus in the 
new-born may be considered pathognomonic of syphilis. Bouchut 
saw a seven and a half months' infant born alive with an erup- 
tion of a copper-color upon the legs and arms, and onyxis upon the 
fingers and toes. Condylomata, mucous patches, and stains of a 
copper-color are the principal syphilitic affections, besides pem- 
phigus, which have been observed at birth on the bodies of con- 



CLINICAL HISTORY. 



151 



taminated infants. It is stated that M. Cullerier, in ten years' 
attendance at the Hopital de Louraine, met only two cases of syphi- 
litic manifestations at birth, and Victor de Meric only two cases 
in forty-six infants, who were affected with congenital syphilis 
(Bumstead) ; but in the practice of others a larger proportion have 
exhibited symptoms at birth. Ordinarily the period in which 
congenital syphilis is first revealed by symptoms is between the 
fifteenth and fortieth days. Rarely the manifestation of the dis- 
ease is delayed several months. M. Diday ascertained the time of 
the commencement of symptoms in 158 cases, as follows: — 



Before the completion of one month after birth, in 
" " two months " 

" « three " " 

At four months 
" five " 
" six " 
" eight '" 
" one year 
" two years 



86 
45 
15 

7 
1 
1 
1 
1 
1 



In cases of tardy commencement of syphilitic symptoms it is 
probable that the disease has been partially eradicated from the 
affected parent by appropriate treatment. 

The nutrition of the infant who has inherited the syphilitic 
taint, but does not exhibit it at birth, is for a time good, but it 
begins to be impaired when the local manifestations of syphilis 
appear, or soon after. The system gradually wastes ; the skin loses 
its fresh and healthy appearance, and becomes sallow, and, after a 
time, more or less wrinkled; the features become pinched or con- 
tracted, and wear a sad expression. M. Diday says : " Next to this 
look of little old men, so common in new-born children doomed to 
syphilis, the most characteristic sign is the color of the skin." 
Trousseau thus describes this discoloration of the surface: " Before 
the health becomes affected, the child has already a peculiar appear- 
ance ; the skin, especially that of the face, loses its transparency ; 
it becomes dull, even when there is neither puffiness nor emacia- 
tion ; its rosy color disappears, and is replaced by a sooty tint, 
which resembles that of Asiatics. It is yellow or like coffee mixed 
with milk, or looks as if it had been exposed to smoke ; it has an 
empyreumatic color, similar to that which exists on the fingers of 
persons who are in the habit of smoking cigarettes. It appears as 
if a layer of coloring had been laid on unequally; it sometimes 
occupies the whole of the skin, but is more marked in certain 
favorite spots, as the forehead, eyebrows, chin, nose, eyelids — in 



152 SYPHILIS. 

short, the most prominent parts of the face ; the deeper parts, such 
as the internal angle of the orbit, the hollow of the cheek, and that 
which separates the lower lip from the chin, almost always remain 
free from it. Although the face is commonly the part most affected, 
the rest of the body always participates more or less in this tint. 
The child becomes pale and wan." 

The infant whose system is profoundly affected by syphilis 
rarely smiles, and its voice is feeble and plaintive ; its frequent 
whimpering cry is quite characteristic. 

Coryza is one of the earliest and most constant of the local affec- 
tions which occur in infantile syphilis. It is slight at first, attracting 
little attention from the parents, who are not aware of its signifi- 
cance, and usually attribute it to a slight cold ; but it gradually 
increases. It gives rise to a secretion from the Schneiderian mem- 
brane, at first thin, but which becomes more consistent, and is 
attended by the formation of scabs. The thickening of the mucous 
membrane in consequence of the inflammation and the presence of 
crusts narrows the passage through the nostrils so as to produce 
snuffling respiration, and sometimes render nursing difficult. In 
severe cases respiration through the nostrils is almost wholly pre- 
vented, so that death may occur from inanition, unless the breast 
is milked into the infant's mouth or it is fed with a spoon ; but 
ordinarily, even in grave coryza, it continues to nurse, though 
obliged often to release its hold of the nipple to obtain breath. It 
is when coryza begins to interfere with lactation that it first alarms 
the parents. The inflammation at the same time may affect the 
throat and larynx, causing hoarseness of the voice. Ulceration of 
the Schneiderian membrane and the subjacent cartilage or bone is 
rare in infancy or childhood, although cases occur which are even 
attended with more or less flattening of the nose. Diday believes 
that the discharge which accompanies coryza is in great part due 
to mucous patches developed on the Schneiderian membrane. The 
upper lip, over which the discharge flows, becomes red, excoriated, 
and more or less incrusted. The coryza, in most cases, coexists 
with other local syphilitic affections. Occasionally it occurs alone, 
and is the only evidence of the presence of the specific taint, except 
such as is afforded by the mal-nutrition and general appearance of 
the patient. 

Mucous patches occur in most patients. They are developed either 
upon the mucous surfaces, or upon parts of the skin which are 
thin and exposed to friction, and such as are moistened by secretion 
or transudation from the vessels underneath. The most common 



ACNE, IMPETIGO, AND ECTHYMA. 153 

seat of mucous patches is at the termination of mucous canals ; 
but in infancy, on account of the peculiar delicacy of the skin, 
they may occur upon almost any part of the cutaneous surface. 
They are most common, however, around the anus, upon the vulva, 
scrotum, umbilicus, labial commissures, in the axillae, and behind 
the ears. 

Mucous patches upon the skin present a rounded border, and 
are slightly elevated. Their color has been compared to that of 
the skin which has been softened by the prolonged application of 
a poultice. Erosions and cracks sometimes occur in the patches, 
from which a thin liquid exudes. 

Upon mucous surfaces they are less elevated than upon the skin, 
and are prone to ulcerate. These ulcerations, commencing at the 
centre, extend, and soon the mucous patch disappears, and its site 
is occupied by an ulcer. The ulcer may be circular, oval, elliptical, 
crescentic, or irregular. The arches of the fauces are a common seat 
of mucous patches. 

Roseola is an occasional symptom of infantile syphilis. "It is 
distinguished," says Diday, "by patches of a bright rose-color, cir- 
cumscribed, irregularly rounded, of various sizes (most frequently 
about as large as one of the nails); appearing, by preference, on 
the belly, lower part of the chest, neck, and inner surface of the 
extremities." The spots do not readily and fully disappear by pres- 
sure. 

Pemphigus appearing soon after birth has already been alluded 
to. Its most frequent seat, whether occurring after birth or as a 
subsequent manifestation, is the palms of the hands, soles of the 
feet, the fingers, and toes. This eruption commences by a violet 
tint of the skin, and in the course of twenty-four to forty eight 
hours a watery fluid collects underneath, which soon becomes 
turbid. The skin peels off, and sometimes an angry sore results, 
which bleeds readily when rubbed or pressed. In other and more 
favorable cases new skin takes the place of that which is lost. 
Pemphigus at birth is a precursor of death, but when it appears 
for the first time some weeks after birth, it is a less unfavorable 
prognostic. In cases of recovery it disappears, with proper treat- 
ment, in two or three weeks. 

Acne, impetigo, and ecthyma are occasionally observed in children 
afflicted with syphilis. The indurated pustules of acne occur most 
frequently upon the shoulders, back, chest, and buttocks. The 
pus is sometimes absorbed, and in other cases discharged, leaving a 
small cicatrix, which, after a time, disappears. Impetigo appears 



151 SYPHILIS. 

most frequently upon the face, and occasionally upon the chest, 
neck, axilla, and groins. Unlike simple impetigo, the syphilitic 
impetiginous eruption is surrounded hy a copper-colored areola. 
Ecthyma occurs upon the legs and buttocks chiefly. It com- 
mences as violet-colored spots, which are soon transformed into 
pustules. Ulcers succeed, which, in reduced states of the system, 
are apt to enlarge, and endanger the safety of the child. Of the 
three pustular eruptions, acne, according to Didaj^, is the least 
serious — indicating a "less confirmed diathesis." Ecthyma is the 
most serious, on account of the reduced state of 'system with 
which it is apt to be associated. Syphilitic papulae and squamae 
are rare in infants, but cases have been observed. Onychia occa- 
sionally occurs, though less frequently than in syphilis of the 
adult. 

Visceral Lesions. — The visceral lesions which occur in the 
syphilis of infancy and childhood are, suppuration in the thymus 
gland; gummy tumors in" certain organs, most frequently the lungs 
and liver; increase of the connective tissue of the liver, known as 
syphilitic cirrhosis; partial perihepatitis, with depressions resem- 
bling cicatrices on the surface of the liver; peritonitis; periostitis, 
with thickening of the bone and exostosis. 

Suppurative inflammation in the thymus gland is not common, 
or has not been frequently observed. "When it is present, the 
gland sometimes presents its normal appearance externally, and 
the abscess is only discovered by incisions. Gummy tumors are 
wjiite and spheroidal; some are as small or smaller than a pin's 
head, while others are as large as a pea, or even a hazel-nut. I 
have seen a considerable number of them not as large as. a pin's 
head, in the liver of an infant. Gummy tumors, according to 
Lebert, consist "of loose fibrous tissue, made up of pale elastic 
fibres, inclosing in their large interspaces a homogeneous granu- 
lar substance, the elements of which are less adherent to each 
other than in deposits of true tubercle." Lebert also, with other 
microscopists, discovered round granular cells in these tumors. 
According to Robin, gummy tumors "are made up of rounded 
nuclei belonging to fibro-plastic cells, or cytoblastions ; of a finely 
granular, semi-transparent and amorphous substance ; and, finally, 
of isolated fibres of cellular tissue, a small number of elastic fibres, 
and a few capillary bloodvessels." 

Constitutional syphilis is one of the principal causes of waxy 
degeneration, and the spleen and liver of infants may be enlarged 
from this cause. Dr. Samuel Gee has expressed the opinion that in 



VISCERAL LESIONS. 155 

half the cases of hereditary syphilis the spleen is enlarged. (Lond. 
Lancet, April 13, 1867.) 

Infiltration of the liver by fibrous substance was first noticed 
by G-ubler. It is not common in the infant. A specimen, showing 
this lesion, was presented to the Londou Pathological Society in 
1866, by Dr. Samuel Wilks. The following remarks by Dr. "VVilks 
convey a good idea of the appearance and state of the liver in 
syphilitic cirrhosis: "Having dissected the bodies of several in- 
fants, who have died of congenital syphilis, I have found fatty 
livers, and an inflammation of the capsule ; but in only two have I 
discovered adventitious products of a fibrous character. The pre- 
sent example, however, corresponds in every particular with the 
disease described by Giibler. It must be distinguished (at least 
as far as the naked eye appearance reaches) from the syphilitic 
disease of adults, of which many specimens have been before the 
Society. In these the organ is cicatrized on the surface, and con- 
tains distinct nodules of fibrous tissue; whilst in the disease of 
children, as in the present specimen, the whole organ is infiltrated 
by a new material, and it consequently becomes, as described by 
G-ubler, hypertrophied, globular, and hard, resistant to pressure, 
and even when torn by the fingers, its surface receives no indenta- 
tion from them ; it is also elastic, and when cut creaks slightly under 
the scalpel. This was the form of disease in the present specimen. 
It came from a syphilitic child, a month old, in whom the liver 
could be felt enlarged during life, and when removed weighed a 
pound and a half. It was smooth on the surface, and so hard that it 
resembled rather a fibrous tumor than a liver." It is seen that the 
liver in the syphilitic child is liable to three distinct pathological 
processes, namely, gummy tumors, cirrhosis or fibroid degeneration, 
and waxy degeneration. 

Syphilitic perihepatitis and periostitis are more rare in infancy 
and childhood than in adult life, but they occasionally occur. Prof. 
Simpson, of Edinburgh, considers peritonitis in the foetus one of 
the results of syphilis, and the cause of its death. 

Mr. Hutchinson, of London, has called the attention of the pro- 
fession to certain observations of his, which, if corroborated, are 
important. According to him, hereditary syphilis becoming latent, 
sometimes manifests itself again after the age of five years, by 
another set of symptoms. One of these manifestations is a dwarf- 
ing of the incisor teeth, which are rounded and peg-like, with 
notched edges. On account of the shape and small size of the teeth , 
there are interspaces between them. This malformation is most 



156 SYPHILIS. 

marked in the central incisors of the upper jaw, and in certain 
cases it is limited to them, and it never appears in the other in- 
cisors unless it does also in them. Another symptom, which only 
appears in hereditary syphilis, is an interstitial keratitis occur- 
ring on hoth sides, and attended by the deposition of fibrin in the 
substance of the cornea. In a few weeks the inflammation de- 
clines, but a slight opacity of the cornea remains. The cerebral 
nerves may become affected, usually a single pair — if the audi- 
tory, deafness resulting; if the optic, dimness of sight. Occasion- 
ally there are other manifestations of syphilis in this period, as 
enlargement of spleen and liver, and nodes upon the long bones. 

Prognosis. — This depends in great part on the general condition 
of the patient. If there is much emaciation, and the symptoms 
indicate a deeply-seated cachexia, a considerable proportion perish. 
On the other hand, if the general health is not greatly impaired, 
although the local affections are pretty severe, the prognosis with 
correct treatment is good. The younger the infant, when the 
symptoms of syphilis appear, the more unfavorable, as a rule, is the 
prognosis. 

Treatment. — Parents who beget syphilitic children ought, from 
a due regard for their offspring, to make use of anti-syphilitic reme- 
dies, although they present in their persons no evidences of syphi- 
litic taint. A good prescription for the parents is one-sixteenth of 
a grain of corrosive sublimate in the compound tincture of bark, 
given twice or three times daily for several weeks. If the father 
has had syphilis, both parents should be subjected to this treat- 
ment, and it may be continued, at least on the part of the mother, 
during the first months of her gestation. So small a dose of the 
mercurial does not, in my opinion, materially increase the liability 
to miscarry. There is much more danger of miscarrying from 
allowing the syphilitic taint to remain uncontrolled. Some prefer 
the use of mercurial ointment in the treatment of pregnant women 
for syphilis, in the belief that it is less likely to produce abortion. 
It is used for this purpose in the proportion of one drachm to the 
ounce. It is equally effectual in the eradication of the syphilitic 
taint with the small dose of corrosive sublimate, recommended 
above for internal administration; but it is impossible to deter- 
mine the quantity of mercury which enters the circulation when 
inunction is employed, and salivation is more likely to occur. 

Syphilis in the infant requires mercurial treatment as in the 
adult. Mercury may be employed internally or by inunction. 
Some prefer inunction in the treatment of ordinary cases, in the 



TREATMENT. 157 

manner recommended by Sir Benjamin Brodie. "I have spread/' 
says he, "mercurial ointment, made in the proportion of a drachm 
to an ounce, over a flannel roller, and bound it round the child, 
once a day. The child kicks about, and, the cuticle being thin, 
the mercury is absorbed. It does not either gripe or purge, nor 
does it make the gums sore, but it cures the disease. I have 
adopted this practice in a great many cases, with the most signal 
success." Trousseau, on the other hand, discountenances the use 
of inunction, as mercurial ointment applied to the skin produces 
irritation, and increases the suffering and restlessness of the child. 
He prefers the following solution, which is known as Yan Swie- 
ten's, for internal treatment : — 

R. Hydrarg. bicklorid. 1 part; 
Aquae 900 parts ; 
Spts. rectific. 100 parts. Misce. 
Dose, one, or at most, two grammes (23 to 46 gr.) in milk, daily. 

As regards the choice between inunction and internal treatment, 
it may be said that the former is preferable in very reduced states 
of system, and in those who are affected with diarrhoea. The 
ointment should not be applied to much of the surface; two or 
three square inches are sufficient. To avoid inflaming the surface, 
the position of it may be varied from time to time, and it need not 
be continuously applied. In cases other than those excepted above, 
I prefer internal treatment. Yan Swieten's liquid may be given, 
or one of the following formulse may be employed : — 

R . Hydrarg. cum creta gr. iij-yj ; 
Sacch. alb. 9j. Misce. 
Divid. in chart. No. xii. One powder 3 times daily. 

R. Hydrarg. cnlor. corros. gr. i-ij ; 
Syr. sarsse comp. ^ij ; 
Aquas 5 viij . Misce. 
One teaspoonful 3 times daily. 

Mercury, in whatever way employed, should not be discontinued 
entirely till several weeks after the syphilitic symptoms have dis- 
appeared; it is proper -to continue it for a time, in diminished 
quantity, after the health seems fully restored. 

When the mercurial is omitted, tonics are often required. The 
preparations of cinchona are useful in certain cases, as are also 
those of iron. If the patient remain feeble and pallid, present- 
ing evidences of struma, cod-liver oil and syrup of the iodide 
of iron will be found beneficial continued for some weeks or months 
after the mercurial is discontinued. Attention should always be 



158 SYPHILIS. 

given to cleanliness and the hygienic management of the child. 
In some instances direct treatment of the local affections is service- 
able. Injections of a solution of chlorate of potash into the nos- 
trils have a good effect in syphilitic coryza, and the application to 
the inflamed surface daily of citrine or white precipitate ointment- 
diluted with an equal amount of lard. Condylomata or mucous 
patches seated upon the cutaneous surface may he dusted with calo- 
mel. At my clinique in April, 1871, a child two years and ten 
months old was presented, with a large condylomatous outgrowth 
near the anus. The history of the child showed that in all proba- 
bility the disease had been contracted within a year from syphilitic 
children in one of the public institutions. Within three weeks this 
affection nearly disappeared by dusting upon it calomel daily, with 
appropriate internal treatment. 



SECTION II. 

ERUPTIVE FEVERS. 



CHAPTER I. 

MEASLES. 



The disease known in the vernacular as measles has also the 
names rubeola and morbilli. It is a common exanthematic affec- 
tion, occurring at any age, hut most frequently in childhood. It 
affects once the majority of mankind. Writers recognize three 
stages of measles: first, that of invasion, which ends with the 
appearance of the eruption; secondly, the eruptive stage; and 
thirdly, the stage of decline or desquamation. 

Symptoms. — This disease commences with such symptoms as usu- 
ally occur in mild hut pretty general inflammation of the air-pas- 
sages, namely, cough, fever, anorexia, and thirst. The eyes present 
a suffused, moderately injected, and brilliant appearance, and the 
buccal and faucial surface is injected. The Schneiderian mem- 
brane, and that lining the larynx, trachea, and bronchial tubes, 
participate in the increased vascularity. The cough at first is dry, 
and sometimes distinctly croupy. Catarrhal or false croup, indeed, 
is not infrequent in the initial period of measles. The cough is 
attended by little acceleration of respiration, and by little or no 
pain in the respiratory movements. If auscultation is practised at 
this early stage, we observe the vesicular murmur, somewhat harsh 
in character, and sometimes sonorous and sibilant rales. A little 
later, rales of a moist character appear. 

The patient, if old enough, commonly complains of headache. 
and of dull pain in the epigastric region or the centre of the ster- 
num, due to the bronchitis. With these local symptoms febrile 
reaction occurs. The temperature rises to about 102° or 103°, as 
indicated by the thermometer in the axilla. The pulse numbers 
from 110 to 130 per minute. The fever is somewhat greater than 



160 MEASLES. 

in primary tracheo-bronchitis, except when the bronchitis becomes 
capillary, but it is less than in most cases of scarlet fever. 

The fever in the premonitory stage of measles after the first day 
is not uniform. It is attended by remissions and exacerbations, 
the former occurring in the first part of the day, the latter in the 
evening. Sometimes two exacerbations occur in the day. The 
face is flushed and somewhat swollen, especially during the times 
of increase in the fever, and the child is drowsy or restless. Vom- 
iting, so common a symptom in the commencement of scarlet fever, 
occasionally occurs in measles. While in scarlet fever this takes 
place in the first twenty-four hours, in measles it occurs with about 
equal frequency at any period previously to the eruption. It was 
present during the first stage, sometimes almost as late as the erup- 
tive period, in thirteen, and was absent in twenty-three cases, of 
which I have preserved records. 

The duration of the first stage varies in different cases. It is 
usually from two to jive days, with an average of about four. Oc- 
casionally it is more protracted on account of some disturbance in 
the economy, either from exposure to cold or other cause, which 
prevents the necessary afflux of blood towards the surface, and re- 
tards the eruption. In eighteen cases in my practice in which the 
duration of the cough previously to the appearance of rash was 
accurately ascertained, the time varied from one to five days, with 
an average of three and one-third; in ten other cases it had con- 
tinued, the parents stated, about a week, and in iive, from one to 
two weeks, previously to the eruption. 

The eruption commences, when the disease pursues its normal 
course, upon the forehead and neck, then the face, and gradually 
extends downwards, occupying from twenty-four to thirty-six 
hours in passing over the trunk and limbs. It appears first as 
indistinct red points not more than a line in diameter, which in- 
crease in size and become more distinct. Their borders are uneven 
or irregular, or they are finely notched; their general shape is, how- 
ever, circular, except as two or more unite, when they may assume 
any form. The crescentic form which writers describe is due to the 
union of two points of eruption. The largest of these spots, when 
there is no coalescence, do not exceed a quarter of an inch in diam- 
eter, and many are much smaller. Frequently in plethoric chil- 
dren, if there is much fever, there is continuous redness over seve- 
ral inches of surface. The eruption is then confluent. This form is 
often observed upon parts of the surface where the capillary circu- 
lation is most active, when it is discrete elsewhere. In some of 



SYMPTOMS. 161 

these cases, diagnosis of measles from scarlet fever is attended with 
difficulty. 

The rubeolous eruption is slightly elevated. This is not appre- 
ciable to the sight, but can be ascertained by passing the finger 
slowly over the skin, when a little roughness is felt at the point of 
eruption. Sometimes the elevation, especially in the commence- 
ment of the eruption, is not appreciable, even to the touch. The 
eruption is broad and flat, never acuminate, never changing its form 
to the vesicular or pustular. It disappears by pressure, and imme- 
diately reappears when the pressure is removed. It has been com- 
pared in appearance to flea-bites. Small, pointed, papular, vesicular, 
or pustular eruptions are sometimes seen in connection with those 
of measles, but they are accidental, occurring in other states of sys- 
tem as well as in measles, if there is the same augmented tempera- 
ture. 

In the commencement of the eruptive period, the severity of the 
constitutional and local symptoms increases. The pulse and tem- 
perature correspond with the character which they presented during 
the exacerbations of the first stage. The features are slightly 
swollen; the eyes still watery and sensitive to light; the conjunc- 
tiva, ocular and palpebral, and the mucous membrane of the cavity 
of the mouth and of the air-passages, continue injected. The 
tongue is covered with a moist thin fur, and its papillae are promi- 
nent, though less so than in scarlet fever. The cough continues 
frequent, and is seldom attended with much expectoration, in un- 
complicated cases ; often there is no expectoration whatever. The 
appetite is lost, but drinks are readily taken on account of the 
thirst. Diarrhoea sometimes occurs on the first day of the eruption, 
but it lasts only a few hours, and, if the disease pursues its usual 
course, abates of itself. With the exception of this, the bowels 
are regular, or a little constipated during the eruptive period. 

On the second day of the eruption, or sixth of the fever, the 
symptoms begin to abate. The pulse is less accelerated, and the 
temperature diminishes ; the cough is less frequent and is easier, 
and the flushed and swollen appearance of the face declines. By 
the close of the third or on the fourth day, the rash has disappeared 
in the order in which it extended over the body. There only re- 
main faint maculae, which in the course of a day or two fade 
completely." 

With the disappearance of the rash, the fever nearly or quite 
ceases, but a slight and painless cough continues for several days. 

Occasionally the eruption presents a livid appearance ; this is 
11 



162 MEASLES. 

the rubeola nigra of writers. From cases which. I have observed, 
it is my opinion that this should not be considered a distinct species 
in the vast majority of cases, but that the dark color is due to in- 
ternal inflammation, usually capillary bronchitis or pneumonia, 
which prevents full oxygenation of the blood. Rarely rubeola 
nigra is due to the vitiated state of the blood, or the malignant 
nature of the disease. The course of the eruption in this form of 
measles is somewhat different ; it continues longer, fades more 
slowly, and does not disappear so readily on pressure. Traces of 
it are observed a week or more after its first appearance ; it is apt 
to be fatal. Measles may present this form from the beginning, or 
commencing as vulgaris, it may pass into rubeola nigra. 

Measles may be irregular in form, but aberrations are less fre- 
quent than in scarlet fever. Writers describe measles without 
catarrh, and, on the other hand, measles without the eruption. 
But positive diagnosis in such cases must be difficult. It is pro- 
bable that simple catarrh and roseola have sometimes been mis- 
taken for the two forms of irregularity mentioned. But when a 
child, in a family of children affected with measles, presents all 
the symptoms of that disease, except the catarrh or except the 
eruption, the diagnosis of irregular measles would, as a rule, be 
correct. 

Occasionally the stage of invasion is very short, or even absent. 
In one case the parents informed me that the catarrhal symptoms 
began on the day when the eruption appeared. Convulsions some- 
times occur at the commencement of measles, as well as during its 
progress. A single convulsive attack at the commencement of 
measles is usually not dangerous ; when repeated, it is more serious; 
it is also more serious when it occurs in the course of measles. 
In certain cases the eruption appears in an irregular and partial 
manner, occurring, perhaps, at a late period, and indistinctly 
upon the trunk alone, or upon the trunk and partially upon the 
legs. In many cases of deferred or partial eruption there is internal 
congestion or inflammation of some part, which causes withdrawal 
of blood from the surface, and thus prevents the normal develop- 
ment of the rash. 

"When the eruption disappears, the third stage commences, that 
of desquamation. It is characterized by a scanty furfuraceous 
exfoliation of the epidermis. The desquamation is seldom as great 
as in scarlet fever, and it occurs most where the eruption has been 
thickest and the epidermis most inflamed. Exfoliation occurs 
between the fourth and seventh days after the commeu cement of 



COMPLICATIONS. 163 

the eruption, the eighth and eleventh of the disease. In some 
children it does not take place, or is so slight, as not to be observed. 

"With, the disappearance of the rash, the symptoms rapidly abate. 
The pulse becomes more natural, the temperature is reduced, the 
digestive organs return to their normal state, and convalescence 
is established. The cough continues several days after the other 
symptoms abate, but it is less and less frequent, and is not painful. 

Complications. — The complications of this disease are important. 
Much of the success of the physician in the management of measles 
depends on a correct diagnosis and understanding of them. The 
most frequent of these complications are bronchitis and broncho- 
pneumonia. Slight bronchitis is common in measles, but if it in- 
crease so as to cause embarrassment of respiration, and become a 
source of danger, it is properly a complication. This complication, 
as well as pneumonia, may occur at any period of measles, but it 
commences most frequently in the first stage. Occurring in the 
first stage, it may prevent the regular appearance of the rash ; if 
in the second, it often causes retrocession of it. 

When bronchitis becomes really serious, it usually has invaded 
the minute bronchial tubes. This disease, designated capillary 
bronchitis or suffocative catarrh, I have elsewhere described. The 
clinical history of fatal bronchitis, as a complication of measles, is 
as follows: The respiration, at first not notably altered, becomes, 
by degrees, accelerated, and the patient more and more fretful. 
The pulse, instead of becoming less accelerated, as after the first 
days of simple measles, is daily more rapid, and the respiration 
more frequent and labored. The dyspnoea gradually increases, the 
infra-mammary region is depressed during each inspiration, and 
the subcrepitant rale is heard on both sides of the chest. There is, 
probably, collapse or inflammation of some of the lobules. Finally 
the prolabia and fingers become livid, and death occurs from apncea. 
Capillary bronchitis is diagnosticated from pneumonitis by the 
physical signs. It is in the young child more dangerous than that 
disease, unless perchance the latter be double. A large majority 
of those affected under the age of three years, die. The anatomi- 
cal characters of fatal bronchitis occurring in connection with 
measles, I have had an opportunity to inspect. In an infant who 
died with this complication in the Infants' Hospital in the spring 
of 1867, there were evidences of continuous inflammation from the 
epiglottis to the minutest bronchial tubes. 

Pneumonia as a complication does not differ materially from the 
idiopathic form, except that it is more protracted and fatal. Its 



164 MEASLES. 

form is in most cases catarrhal, resulting from an extension of the 
bronchial inflammation. 

The next most frequent serious complication of measles is entero- 
colitis. This may commence at any period during the course of the 
disease. If the colon is more especially the seat of inflammation, the 
evacuations contain mucus and blood, unless in young children, in 
whom the stools, even in severe colitis, commonly have a green color. 
The anatomical character of this complication varies in different 
cases, like the idiopathic form of inflammation. Sometimes there is 
simple arborescence of the intestinal mucous membrane, with tume- 
faction of its follicles ; in other cases, in addition to increased vas- 
cularity, the mucous coat is softened and thickened ; and in others 
still, especially if the inflammatory action has been somewhat pro- 
tracted, ulceration occurs, for the most part in the site of the soli- 
tary glands. Exceptionally, in fatal cases of measles attended with 
diarrhoea, no vascularity is observed after death, although the 
intestine may be somewhat thickened and softened. In these cases 
the diarrhoea may have been non-inflammatory or inflammatory, 
the injection of the vessels having disappeared after death. 

Severe and obstinate diarrhceal affections occurring with measles, 
usually commence as the primary disease is about declining. They 
then become sequelae, ending fatally in many instances several days 
or perhaps weeks after the disappearance of the eruption. Diar- 
rhceal attacks, occurring in, or previously to, the eruptive stage, are, 
as a rule, mild and easily relieved. 

In some grave cases, measles have a tendency from the first to 
affect the internal organs more than the surface. There then co- 
exist bronchitis, pneumonia, and entero-colitis, with indistinctness 
of the eruption on the skin. Such complications render a fatal 
result highly probable. 

Another very fatal complication and sequel is true croup, com- 
mencing when rubeola is beginning to decline ; but it is less frequent 
than pneumonia or entero-colitis. In catarrhal or false croup, which, 
as has been previously stated, is not infrequent at the commencement 
of measles, the cough has a loud, ringing character. In true croup, 
on the other hand, it is hoarse or harsh, and less distinct, on account 
of the presence of the pseudo-membrane in the larynx. True croup, 
always a grave disease, is more serious when it occurs as a compli- 
cation of measles than in the idiopathic form, not only because the 
blood is vitiated and the system reduced by the primary affection, 
but because the inflammation of the mucous surface is in general 
more extensive, as is also, I believe, the pseudo-membrane. This 



ANATOMICAL CHARACTERS. 165 

membrane in the croup of measles I have seen extend so far down 
the air-passages, that tracheotomy could not have been attended by 
any decided amelioration of symptoms. This complication, though 
always grave, is not, however, necessarily fatal. I have known cases 
recover by ordinary treatment, when for days there had been dysp- 
noea and other evidences of a pretty firm pseudo-membrane. True 
croup causes continuation of the fever, which had perhaps begun 
to abate. 

Diphtheria, when epidemic, also frequently complicates measles. 
Much of the mortality from measles in this city, between the years 
1860 and 1865, was due to this cause. In cases observed by myself, 
diphtheria usually began while the fauces were still inflamed, and 
sometimes before the eruption had begun to fade. 

These are the most common complications of measles. There 
are others of less frequent occurrence, among which may be men- 
tioned congestion of the brain, with or without serous effusion. 
Stomatitis, pharyngitis, and otitis are occasional complications. 
Rarely, also, purpura, attended by hemorrhages from the different 
mucous surfaces, occurs in connection with measles. This compli- 
cation is, however, more frequent in certain other constitutional 
diseases, as scarlet fever, and especially variola. 

It is seen that the inflammations which are apt to occur in the 
course of measles are chiefly of the mucous surfaces. In scarlet 
fever, on the other hand, the inflammations are serous. 

There are other affections, originating in measles, which are 
rather sequelae than complications. Gangrene of the mouth is one 
which, as stated in another part of the work, is more apt to occur 
after measles than any other disease. Ophthalmia commencing in 
measles often persists for weeks or months. It may give rise to 
granulations of the lids, and cases have been reported of violent 
inflammation of a purulent character, producing ulceration of the 
cornea, and destroying vision. The ophthalmia is sometimes very 
intractable. Inflammation of the Schneiderian membrane, com- 
monly present during measles, sometimes continues as a sequel, ex- 
tending back as far as the Eustachian tube, where it may cause 
swelling, with impairment of hearing, and forward to the lip, 
where it may produce chronic eczema. 

Anatomical Characters. — I have made, or witnessed, according 
to remembrance, some six post-mortem examinations of those who 
have died in, or immediately after, an attack of measles. In all 
there were lesions due to complications. Indeed, death directly 
from measles is so rare that few have had an opportunity of study- 



166 MEASLES. 

ing the anatomical characters which are peculiar to this affection. 
In those who have died without any obvious coexisting disease, 
and these cases chiefly occur in the malignant form, there has been 
congestion of the internal organs, especially marked in the lungs, 
and sometimes the tissues appeared softened. The blood, also, in 
the malignant form, has a darker hue than natural, and ecchymotic 
patches have been observed upon the mucous surfaces and elsewhere, 
corresponding in character with the petechia under the skin which 
sometimes occur in this form of measles. In cases resulting fatally 
from bronchitis or pneumonia the bronchial glands are commonly 
tumefied in the same manner as the mesenteric glands are enlarged 
in enteritis, and the glands of the meso-colon in dysentery. 

Mature. — Rubeola, like the other exanthematic fevers, is due to 
a materies morbi, the exact nature of which is unknown. It is 
both inoculable and infectious. It has been inoculated by the 
serum from vesicles which sometimes occur in connection with the 
rubeolous eruption, and also by the blood from a patient. Inocu- 
lation does not appear to moderate the disease, and as measles, 
when contracted in the ordinary way, is not in itself dangerous, 
but dangerous only from complications, inoculation is not per- 
formed, except as a matter of scientific interest. The usual mode 
of propagation is by infection. It is communicated both by the 
breath and clothing. By fomites the virus is sometimes conveyed 
a long distance. The question is still undecided whether rubeola 
does not sometimes occur spontaneously. I have met cases, and 
have been informed of others, one especially, occurring in a sparsely 
settled portion of the country, in which there was apparently no 
exposure, and I incline to the opinion that its origin de novo is 
possible, though not frequent. 

The period of incubation of measles is usually from ten to four- 
teen days. In cases observed in the children's department of 
Charity Hospital, this period was ascertained to be about twelve 
days. In those who have been inoculated, the incubative period 
is said to have been about one week. Rubeola prevails epidemi- 
cally, like the whole class of infectious diseases, and in different 
epidemics the type varies somewhat, as well as the character of 
the complications. 

Diagnosis. — The diagnosis of measles, previously to the eruption, 
is often difficult. The catarrhal symptoms then predominate, and 
these are such as may occur independently of any constitutional 
or blood disease. The first stage, therefore, of measles, is often 
mistaken for coryza, or mild bronchitis. The points of differential 



PROGNOSIS — TREATMENT. 167 

diagnosis are the suffused appearance of the eyes, the greater degree 
of fever on the first day than would be likely to arise from so 
moderate an amount of local disease, and on subsequent days re- 
mission and exacerbation of the fever. Measles in the first stage 
has been mistaken for remittent fever. The catarrhal symptoms 
should prevent such an error. 

Sometimes roseola closely resembles measles in appearance, but 
the rash of roseola appears within a few hours after the commence- 
ment of febrile symptoms, and almost simultaneously over the 
whole body, and without those local symptoms referable to the 
mucous surfaces, which characterize measles. 

Variola on the first day of the eruption has sometimes been 
diagnosticated as measles. I recollect once being called to an in- 
fant with fatal confluent smallpox, who was said to have measles. 
A physician, a few days previously, observing the red points in the 
commencement of the eruption, had made this absurd diagnosis, 
and, predicting a favorable result, had not thought it necessary to 
repeat his visit. In case of doubt, it is the part of prudence to 
defer making a positive diagnosis. A few hours suffice to show 
the distinctive characters of the rubeolous and variolous eruptions. 
But the anxiety of friends often necessitates the expression of an 
opinion. The absence of catarrhal symptoms, the earlier appear- 
ance of the eruption, and its papular feel under the finger in 
smallpox, enable us to discriminate between the two diseases in 
the commencement of the eruptive stage. Moreover, the symp- 
toms in the initial periods are different, as will be seen in our 
description of smallpox. 

Prognosis. — This is favorable, provided that there is no serious 
complication. "With internal inflammatory complication, on the 
other hand, the disease becomes much more grave. A large pro- 
portion thus affected die. The prognosis is also less favorable in 
feeble children with scanty eruption, or an eruption appearing at 
a late period and irregularly. Dyspnoea, persistent and great, 
acceleration of pulse, and coma, indicate an unfavorable ending. 
Convulsions occur much more rarely in the course of measles than 
in scarlet fever, and when they occur after the initial period they 
usually end in coma and death. 

Treatment. — Uncomplicated measles requires no medicinal treat- 
ment except to palliate symptoms. The child should be kept in 
an airy apartment, at a uniform temperature of about 68°. A 
temperature so elevated as to be uncomfortable to the nurse is 
injurious to the patient. But while the popular idea is erroneous, 



168 MEASLES. 

that lie should be kept in a heated atmosphere, it is correct that 
currents of air and sudden reduction of temperature are dangerous. 
A violent and fatal attack of croup occurred in my practice in a 
girl of fifteen, in consequence of exposure at an open window 
during the period of desquamation. The diet should be mild, and 
for the most part liquid. The patient, indeed, refuses solid food, 
but, on account of the thirst, takes liquids more readily. Farina- 
ceous substances, with milk, afford sufficient nutriment in ordinary 
cases. If the previous health has been poor and the vital powers 
reduced, or if there is a complication, more sustaining diet is re- 
quired. Stimulation by wine or brandy is needed in some of these 
cases. During the two or three weeks succeeding an attack of 
measles, care should be taken to avoid exposure to cold, or changes 
of temperature, since during this period mucous inflammations are 
so apt to occur. 

The cough in most cases requires treatment, inasmuch as the 
suffering of the child and loss of sleep are largely due to this 
symptom. Demulcent drinks, as flaxseed tea, infusion of slippery- 
elm bark, or solution of gum Arabic, are useful, to which, to render 
them more palatable, lemon-juice may be added. A small Dover's 
powder, or the following mixture given occasionally, relieves the 
severity and diminishes the frequency of the cough : — 

I£. Tinct. opii campliorat., 
Syr. scillse, 
Syr. ipecac, aa ^ss; 
Spts. aether, nitr. 5ij- Misce. 
Dose, one teaspoonful to a child of five years, repeated according to circumstances. 

As the chief danger in measles is from inflammation of the respi- 
ratory organs, local treatment directed to the chest is important. 
The chest should be covered with oil-silk, unless in the mildest 
cases. This increases the amount of eruption upon the surface 
underneath, and, I believe, tends greatly to prevent complication 
by bronchitis and pneumonia. If the eruption is tardy in its 
appearance, or indistinct, it is well to produce moderate counter- 
irritation by some gentle irritant underneath, as camphorated oil, 
to which one-third part of turpentine is added. 

Affections, which complicate measles, should receive, for the 
most part, such treatment as is appropriate for them when idio- 
pathic. Secondary diseases, however, require sustaining measures 
more than primary. In bronchial and pulmonary inflammations, 
which, if they occur early in measles, prevent the regular appear- 
ance of the eruption, or, if in the eruptive stage, cause its disap- 



SCARLET FEVEE. 169 

pearance, prompt counter-irritation over the chest, by sinapisms or 
otherwise, is required. Trousseau states that he has derived benefit 
in these cases, from what he designates urtication. This is pro- 
duced by stroking the chest two or three times daily with the 
nettle (urtica dioica or urtica urens). This causes a prompt and 
abundant eruption, and with a less amount of suffering than 
one would suppose. The fever abates, and the respiration becomes 
more natural in proportion to the amount of nettle-rash. On the 
second day the effect is less than on the first, and after three or 
four days, says Trousseau, no further irritation results from the 
nettle. "When counter-irritation is produced, by whatever method, 
the chest should be covered with a warm and soft poultice, as the 
ground flaxseed; derivatives to the extremities are useful in such 
cases. In capillary bronchitis and pneumonia stimulating expec- 
torants are required, as senega and carbonate of ammonia. 

As regards the treatment of other complications, the appro- 
priate measures are detailed elsewhere. 



CHAPTEE II. 
SCARLET FEVER. 

The terms scarlet fever, scarlet rash, and scarlatina are identical. 
They are employed to designate one of the most frequent and fatal 
of the contagious diseases, a disease which may occur at any age, but 
is most common in childhood, an exanthem attended with more or 
less pharyngitis. In this city, on account of its great frequency, 
and its large percentage of fatal cases, it causes more deaths than 
any other contagious affection. Though not more common than 
measles, it is attended, with us, by more than double its mortality. 

There is no disease that presents a greater difference, as regards 
character and severity of symptoms, than scarlet fever, and this 
has led to the recognition of different forms of it. Eilliet and 
Barthez describe two, the normal and abnormal ; Meigs two, the 
mild and grave ; and most other writers, three or more. I shall, for 
convenience, follow Bouchut, who makes three varieties, namely, 
the regular, irregular, and malignant. 

Symptoms. Regular Form. — Scarlet fever usually begins ab- 
ruptly. It is possible, often, to tell the exact time of its com- 



170 SCARLET FEVER. 

mencement. If there are premonitory symptoms, they are ordi- 
narily slight, so as scarcely to attract attention, amounting to little 
more than dulness, or the appearance of fatigue. In some the first 
symptom is chilliness, and occasionally a distinct chill is experi- 
enced. This is the ordinary mode of commencement in the adult. 
With or without the chilliness, fever, usually intense, arises, 
accompanied by such symptoms as ordinarily occur in a febrile 
state of system, such as cephalalgia, perhaps delirium, anorexia, 
thirst. The pulse rises to 110, 120, or more, per minute; the skin 
is hot, face flushed, the eyes bright, and occasionally more or less 
suffused. In many, there is sudden starting or twitching, with a 
degree of stupor, showing that the cerebro-spinal system is pro- 
foundly affected. 

In most cases there occurs within the first twenty-four hours 
a symptom which has considerable diagnostic value, namely, 
vomiting. In 117 cases in which I have recorded its presence or 
absence, it occurred in 90, usually not at the very commencement, 
but within the first twelve or eighteen hours. It commonly 
occurred before the appearance of the rash, but not always. In 
a few of the cases it is recorded as a symptom of the second day. 
Vomiting at this period is, probably, in most cases, sympathetic, 
due to the effect of the specific virus of the disease on the brain. 
It is not a severe symptom, occurring in most cases but once or 
twice. Great and persistent irritability of stomach indicates a 
serious form of scarlet fever, and is, therefore, prognostic of an 
unfavorable ending. When this symptom is absent or slight, or 
there is merely nausea, I have found the case ordinarily mild, so 
that, as regards the frequency of vomiting, the statistics of differ- 
ent epidemics vary according to the mildness or gravity of the 
type. The bowels are regular or somewhat constipated in this 
form of scarlet fever, or if diarrhoea occur, it is slight and tran- 
sient. 

"When the symptoms described above have continued six to eigh- 
teen hours, the rash appears. It is first observed about the ears, 
neck, and shoulders, in reddish indistinct patches, fading into the 
normal hue. These patches extend and unite, and in the course of 
a few hours the trunk and upper extremities, and finally the legs, 
are covered. The scarlatinous rash bears considerable resemblance 
to that produced by external heat or the redness from a sinapism, 
but there are numerous minute points of a deeper or duskier red 
than the surface generally. On passing the finger over the erup- 
tion, no distinct prominences are observed, but a sensation of rough- 



SYMPTOMS. 171 

ness is sometimes imparted from engorgement of the cutaneous pa- 
pillae. The rash disappears by pressure, but in robust children, 
and in favorable cases, it immediately returns when the pressure is 
removed. Slow return of the rash is evidence of sluggish circula- 
tion, and, when marked, it indicates the malignant form of the 
disease. The rash gives rise to an itching or burning sensation, 
which adds greatly to the discomfort of the patient. The degree 
of redness is not uniform over the surface, and sometimes, especially 
in mild cases, it is absent in places. 

Early in the disease, even before the cutaneous eruption, the buc- 
cal and faucial mucous membrane presents a pretty general red 
appearance, and the papillae of the tongue are elevated. Pharyn- 
gitis has already commenced, with more or less stomatitis and tonsil- 
litis. The inflammation renders deglutition painful, so that diffi- 
culty is often experienced in giving the necessary drinks. This 
state of the buccal and faucial membrane continues through the 
disease. There is sometimes a slight fibrinous exudation over the 
tonsils ; the tongue is covered with a moist fur, and the secretion 
from the follicles of the inflamed surface is increased and muco- 
purulent. The Schneiderian membrane also participates in the 
inflammation, and, as the disease advances, a thin, irritating dis- 
charge, containing pus cells, flows from the nostrils. 

The temperature in the first days of scarlet fever is ordinarily 
from 102° to 105°, sometimes as high as 107°. The cutaneous trans- 
piration during this period is nearly checked, so that the skin is hot 
and dry. The respiration is moderately accelerated, but not so as 
to attract attention, unless there is a complication ; often there is 
slight cough from mucus in the throat or bronchial tubes. Bron- 
chitis, common in measles, and giving rise to prominent symp- 
toms in that disease, is either absent or slight in scarlet fever. 

The symptoms pertaining to the digestive system during the 
initial period of scarlet fever have been sufficiently described. The 
subsequent symptoms do not differ materially in regular scarlet 
fever, except that there is no vomiting. The lips are dry and often 
cracked. The inflammation of the mouth and throat continues 
unabated, with anorexia and thirst. The urine is high-colored, and 
in robust children, during the first days of scarlet fever, it fre- 
quently deposits the urates on cooling. 

The symptoms continue with undiminished intensity for a period 
of from four to six days, when the fever begins to abate, the pun- 
gent heat becomes less, and the rash fainter. There is a gradual 



172 SCARLET FEVER. 

decline of the disease, which, in its inception, was so abrupt. In 
mild, and even pretty severe cases, which pursue a regular and 
favorable course, convalescence commences by the close of the first 
or beginning of the second week. In the second week, the rash, 
becoming less and less distinct, finally disappears, as do also the 
redness and swelling of the buccal and faucial membrane. The 
engorgement of the papillae of the tongue and that of the tonsils 
subsides; the appetite returns; the countenance brightens, and be- 
comes natural, and the child who, during the height of the fever, 
scarcely noticed objects, or noticed them with indifference, or even 
repugnance, can be amused as before his sickness. 

The period of desquamation succeeds. Exfoliation of the epi- 
dermis occurs over the whole body. This commences about the 
face and neck, and it occupies several days, during which there is 
progressive improvement in the condition of the child. Where 
the skin is thin, the epidermis, as it is detached, presents a furfu- 
raceous appearance ; where it is thick, as upon the palms of the 
hands, and soles of the feet, it separates in a layer of considerable 
thickness. 

Such is a brief account of scarlet fever, when it pursues its nor- 
mal course, without complication or sequelae. But there is no dis- 
ease which has so many unfavorable complications and sequelae as 
this. The liability to these renders the prognosis in all cases doubt- 
ful, and in many instances they are the immediate cause of death. 
They occur both in mild and severe cases of scarlet fever. 

The great difference in different cases of scarlet fever, as regards 
intensity of symptoms, is well known. It is sometimes so mild, 
its characteristic features so slight, that diagnosis is necessarily 
uncertain. Examples in corroboration of this statement are not 
infrequent. In the spring of 1866 I was called to an infant thir- 
teen months old, who had slight pharyngitis, and an indistinct 
rash over a part of the surface. In two days the eruption had 
disappeared, and soon after the health was apparently fully restored. 
Diagnosis would have remained doubtful, except for sequelae. In 
another instance, two children passed through the entire course of 
scarlet fever, playing every day in the street. Although the intel- 
ligent grandmother saw the rash upon them, its nature was not 
suspected till nearly two weeks afterwards, when one was taken 
with fatal nephritis and general anasarca. In cases so mild as 
these, the heat of surface is not greatly increased, nor is the pulse 
much accelerated. There is no restlessness, nor is the digestive 
function materially impaired. The rash does not have so deep a 



SYMPTOMS. 173 

color, nor is it so continuous over the surface, as in cases of ordinary 
gravity. The patient begins to improve in from two to four days, 
and is soon well. So mild a form of scarlet fever is, however, quite 
exceptional, but there are all gradations, from this mildness to that 
malignant form which I shall presently describe. 

There is usually considerable faucial inflammation, even when 
scarlet fever pursues a regular and favorable course. If the pharyn- 
gitis is intense and protracted, many writers designate the disease 
scarlatina anginosa. There is, in these cases, not only general and 
pretty severe inflammation of the mucous membrane of the fauces, 
with swelling of the tonsils, and submucous infiltration, but also 
more or less tumefaction around the angle of the jaw, due to exten- 
sion of the inflammation to the lymphatic glands, and cellular tissue 
of the neck. In these cases, the suffering of the patient is greatly 
increased by the amount of local disease. The adenitis and cellu- 
litis, unless slight, do not subside with the disappearance of the 
rash, or they subside more slowly. They render the febrile move- 
ment more protracted. The swelling due to these inflammations 
often continues one or two weeks after the disappearance of the 
rash, or even longer, when it disappears by resolution, or more 
rarely by suppuration, the abscess opening externally. 

Irregular Form. — The irregular form of scarlet fever is commonly 
due to some perturbating cause. This cause is often a pre-existing 
or coexisting disease, or, if not actual disease, at least disordered 
state of system. For example, a little girl, in my practice, had the 
symptoms of scarlet fever, such as febrile movement and inflamma- 
tion of the buccal and faucial surface, nearly a week before the 
scarlatinous eruption appeared. During this period there were 
symptoms of enteritis, which declined when the rash occurred. The 
abdominal affection was the apparent cause of the irregularity in 
the fever. If scarlet fever occurs during an attack of entero-colitis, 
there is frequently no eruption. Most practitioners have met cases 
like the following, which I now recall to mind: In a family where 
scarlet fever was prevailing, a little child, early after the commence- 
ment of symptoms which seemed to be plainly referable to the ex- 
anthematic affection, was seized with vomiting and purging, and the 
latter continued two or perhaps three days, when death occurred. 
There were top symptoms and appearances of severe scarlet fever, 
but without the eruption. In another instance, an infant in the 
warm months having protracted entero-colitis, the usual summer 
epidemic of this city, was apparently affected with scarlet fever, 



174 SCAELET FEVER. 

which was present in the family. There were the characteristic 
symptoms, but the diarrhoea continued, and there was no rash. 

In those that are much reduced by any antecedent disease, as 
phthisis, or that have a disease, chronic or acute, which produces 
a decided afflux of blood towards an internal organ, the eruption is 
commonly tardy in its appearance, indistinct, or wholly absent. 
The diseases which most frequently render scarlet fever irregular 
are those of an inflammatory nature. Some affections, occurring 
in connection with scarlet fever, do not change its symptoms, but 
themselves undergo modification. Scarlet fever occurring in a child 
having pertussis does not itself undergo any material change. The 
cough, not the fever, is modified (rendered milder) during the 
coexistence of the two. 

Scarlet fever may, also, be irregular in those that are robust and 
free from any other disease assuming this form, without any appre- 
ciable perturbating cause. In 1867 I attended a young lady, whose 
previous health was excellent, and whose brother was sick at the 
time with scarlet fever. This patient had considerable fever, with 
pretty severe pharyngitis, and though her surface was repeatedly 
examined, no eruption could be discovered. Two weeks subse- 
quently she became affected with severe nephritis, anasarca, effu- 
sion into at least one of the pleural cavities, and probably into the 
pericardium, the case ending fatally. 

Eilliet and Barthez mention the irregular and incomplete char- 
acter of the eruption in second attacks of scarlet fever, which, 
though uncommon, are met from time to time. Scarlet fever 
occurring a second time, sometimes presents all the features of the 
regular disease, and pursues its normal course, but it is much more 
apt to be incomplete and irregular than the first attack. It is 
more apt to be irregular if the interval between the two has been 
short, than if several years have elapsed. 

Malignant Form. — This form of scarlet fever is in some epidemics 
common, while in others it is rare. It usually commences with 
severe symptoms, those pertaining to the nervous system predomi- 
nating, such as intense cephalalgia, with delirium. Many pass 
rapidly into coma, and die within two or three days. They suc- 
cumb to the virulence of the scarlatinous poison, while the disease 
is still in its commencement. The rash in malignant scarlet fever 
is dusky. It disappears by pressure, and returns slowly when the 
pressure is removed. There is, therefore, extreme sluggishness of 
the capillary circulation. In some there is great restlessness. If 
placed in one position on the bed, they soon throw themselves, in a 



COMPLICATIONS. 175 

half-conscious' or unconscious state, into another. They do not 
speak at all, or they mutter like those affected by the graver forms 
of typhus, calling the names of playmates, or talking about things 
which interested them when well. There is great elevation of 
temperature, the thermometer, placed in the axilla, indicating 103°, 
105°, or even 107°, and the heat of surface is pungent, except when 
the case approaches a fatal termination. The pulse from the first 
is rapid, numbering from 130 to 160 per minute. Sometimes there 
is great heat of head and body, while the limbs are cool. This is 
an unfavorable sign. 

Severe and dangerous nervous symptoms, as convulsions and 
coma, occur chiefly within the first three or four days. After this 
period the danger is mainly from exhaustion. Those who survive 
the onset of the disease, often have, in the course of a few days, 
severe pharyngitis, with inflammation of the lymphatic glands, and 
cellular tissue around the angle of the jaw, accompanied by external 
swelling. The pharyngitis is attended by more or less secretion of 
mucus or muco-pus, which, sometimes collecting around the en- 
trance of the larynx, causes noisy respiration, or even, if the system 
is greatly prostrated, embarrasses respiration by entering the larynx. 
The chief danger, however, from the pharyngitis, is due to the 
exhaustion which it causes. By rendering deglutition difficult, it 
interferes seriously with nutrition. 

Complications. — Complications may occur in any form of scarlet 
fever, but they are most frequent in malignant or grave cases. The 
most common and serious complication, as regards the nervous 
system, is clonic convulsions. These occasionally occur at the com- 
mencement of the disease, before the appearance of the rash, and 
many then recover, but I have not seen, nor have I heard, in my 
intercourse with physicians, of any case which recovered when con- 
vulsions occurred after the complete development of the eruption. 
On the other hand, some of the physicians of this city, of largest 
experience, inform me that they consider convulsions during the 
eruptive stage an almost certain precursor of death. Convulsive 
attacks in scarlatina are probably due, in part, to congestion of the 
nervous centres, for we sometimes find, in young children, at the 
time of the seizure, and immediately before it, the anterior fonta- 
nelle prominent, and forcibly pulsating. The convulsions uniformly 
increase the congestion, but, as the latter antedates the former, its 
causative relation seems to be established. But the most important 
element in the causation of convulsions in scarlet fever is, probably, 
the presence in the blood of the scarlatinous virus. This, whatever 



176 SCARLET FEVER. 

its exact nature, may, in my opinion, cause convulsions, with or 
without the co-operating influence of congestion, as urea gives rise 
to them in cases of uraemia. Convulsions occurring at the com- 
mencement of scarlet fever are ^usually single. If repeated, they 
become more serious. Convulsions after the appearance of the 
eruption, either end at once in coma, or they return at short inter- 
vals, with gradually increasing drowsiness, till coma supervenes. 

The anginose affection in scarlet fever may be so severe, or assume 
such features, as to constitute a complication. It may become more 
serious than the primary disease itself, so as to require the chief 
treatment. During the recent epidemic of diphtheria in this city 
many cases were observed in which diphtheria and scarlet fever 
coexisted. As has been stated elsewhere, a pseudo-membranous 
formation upon the faucial surface, especially over the tonsils, is 
not uncommon in severe anginose scarlet fever, but is soft or pulta- 
ceous, in isolated points or patches, and easily detached. On the 
other hand, in the cases to which I have alluded, of diphtheritic 
complication, the pseudo-membrane is firm and thick, penetrating 
the mucous membrane so as to produce bleeding when forcibly de- 
tached, as in primary diphtheria. In one instance in my practice 
the coexistence of diphtheria and scarlet fever was very apparent. 
Two children in a family died after a short attack of malignant 
scarlet fever. Their throats were not examined. Another child 
took the disease, and, being longer sick, it was more carefully ex- 
amined. The diphtheritic, pseudo-membrane was found on both 
tonsils, at the same time that there was a distinct scarlatinous rash, 
and, as additional proof of the coexistence of the two diseases, the 
father became affected with diphtheria without scarlatina. 

An occasional result of severe pharyngitis in scarlet fever is 
suppuration, or gangrene occurring in the subcutaneous cellular 
tissue of the neck. Whether suppuration occur, and an abscess 
form, or gangrene result, this complication is often serious. Sup- 
puration or gangrene indicates an intense grade of inflammation 
or a low vitality ; but many with this complication recover through 
protracted convalescence. 

If suppuration is extensive, it may so increase the debility that 
death occurs in consequence. Gangrene is a more serious compli- 
cation; unless slight, it renders a fatal termination highly probable. 
The areolar tissue, subcutaneous or intermuscular, is the part 
which primarily sloughs. The skin over the gangrene becomes 
brown or dark, and separates with the slough. In the majority of 
cases the slough is not large. Exceptionally it extends so deeply 



COMPLICATIONS. 177 

that, when it separates, the muscles and even vessels of the neck 
are laid bare, and the appearance is hideous. In a case of this sort, 
which I saw a few years since in the practice of another physician, 
the cavity, after the slough had separated, was irregular, and 
sufficiently large to admit a hen's egg. It extended a considerable 
distance out of sight under the skin, and finally opened a vessel 
from which fatal hemorrhage occurred. 

Gangrene of the mouth also occurs in rare instances, either as 
a complication or sequel. I have met it in two cases, one of 
which recovered. In the fatal case it began while the patient was 
still under treatment for the fever, and was first discovered by the 
loss of two incisors. The one that recovered also lost two in- 
cisors, and a part of the superior maxillary bone. The one that 
died was scrofulous, though its regimen was good ; the other lived 
in a tenement-house, and was ill cared for. Rilliet and Barthez 
relate three cases of gangrene of the mouth, occurring, however, 
not as a complication, but sequel, of scarlet fever. One of these 
patients had, within eighteen days, varioloid, scarlet fever, and 
measles ; these diseases ending in fatal gangrene of the pharynx 
and mouth. The second child was taken, on the seventeenth day 
after the commencement of scarlet fever, with gangrene of the 
pharynx, succeeded by that of the mouth, and died on the twenty- 
fourth day. In the third case the gangrene was preceded by small- 
pox as well as scarlatina. Other observers have recorded similar 
cases. 

Another complication, to which allusion has already been made, 
is entero-colitis. This may antedate the zymotic affection. In 
other cases, entero-colitis commences either with the scarlet fever, 
or during its course. Diarrhoea often occurs in connection with 
the vomiting, in the first hours of the fever; and it commonly 
ceases during the first or second day. Occasionally it continues 
with greater or less severity, when it constitutes a serious compli- 
cation ; it is in these cases due to intestinal inflammation. Bron- 
chitis and pneumonia, so common in measles, do not often compli- 
cate scarlet fever. 

A not infrequent complication is articular rheumatism, occurring 
when the fever begins to decline. Mild cases are more liable to it 
than those having a severe form. Attention is called to it by 
the complaint of the child of pain or tenderness in the affected 
joints; or, if he is too young to speak, by evidences of pain when 
the joints are pressed or moved. There are usually but little 
swelling and redness, and there are fewer joints affected than in 
12 



178 SCARLET FEVER. 

most cases of acute primary rheumatism. In my practice, a com- 
mon seat of scarlatinous rheumatism has been the areolar tissue of 
the wrist. The inflammation and infiltration are less than in 
primary acute rheumatism. This complication is not, ordinarily, 
serious ; nor does it, as a rule, materially retard convalescence. A 
physician of this city, however, informs me of two cases in which 
cardiac inflammation occurred in connection with the articular 
affection, as it so frequently does in idiopathic rheumatism. The 
urates are not so commonly present in the urine in scarlatinous as 
in ordinary acute rheumatism. 

Serous inflammation, especially that affecting the peritoneum, 
pleura, or pericardium, is a common complication, independently of 
the rheumatic affection. It occurs during the desquamative period, 
and, continuing afterwards, becomes a sequel. Many such cases 
are fatal. Pericarditis may be with difficulty diagnosticated, if it 
is slight, and attended by only a moderate amount of effusion, and 
it is, doubtless, often the cause of death in those who die suddenly 
and unexpectedly during or soon after an attack of scarlet fever. 
Pleuritis occurring in scarlet fever is apt to be suppurative. In 
1865 I attended a little girl in a mild attack of the fever. When 
it had nearly ceased, and the case was about being discharged, she 
was taken with severe pleurisy of the right side. The pleural 
cavity was soon half filled with liquid, and after a long sickness, 
extending over two months, this liquid, mainly pus, established a 
communication with a bronchial tube, and was expectorated. She 
immediately recovered. 

In the following case, the records of which are from my note- 
book, pericardial and peritoneal inflammation occurred as a com- 
plication of scarlet fever: — 

Case. — April fth, 1860, C — , girl, five years and ten months old, had 
measles two years, and hooping-cough one year ago. With the excep- 
tion of a slight cough, she has since remained well, till the present 
sickness. Scarlatina commenced April 4th, and on the 5th the eruption 
appeared. Symptoms severe, but regular ; pulse 158, full ; surface hot, 
and covered with the eruption ; delirium at night ; stomach irritable ; 
constipation. April 8th to 10th, symptoms about the same; no delirium, 
however; pulse varying from 124 to 153 per minute ; a deposit of urates 
in the urine. 

11th. To-day, for the first, has severe pain in the epigastrium, ac- 
companied by tenderness on pressure, and moderate distension at this 
point. The symptoms otherwise are favorable, though pretty severe ; 
pulse 140 ; respiration moderately accelerated, but the rhythm natural ; 
respiratory murmur distinctly heard in all parts of the chest, vesicular 
in character, and without rales. Has taken till to-day mainl}' - diapho- 
retic mixtures; to-day pulv. ipecac, comp. gr. iij, every three or four 



SEQUELAE. 179 

hours, is ordered ; a flaxseed poultice to be applied to the epigastrium ; 
diet nutritious, with moderate use of stimulants. 

12th. Epigastric pain still severe; great tenderness on pressure; con- 
siderable distension at this point, and percussion elicits a dull sound ; 
passed a restless night ; when asked where she feels pain, she points to 
the throat and epigastric region; pulse 130 to 140 per minute; rash 
fading ; surface warm ; bowels somewhat relaxed ; urine passed in usual 
quantity. The treatment by Dover's powder and poultices is continued, 
and a leech is to-day applied to the epigastrium. 

13th. Pain less severe, but considerable tenderness on pressure; pulse 
about the same as yesterday ; has had through her sickness a slight 
cough. She talks rationally, and sits much of the time in bed. 

14th. Continued in the same state as described in yesterday's records, 
till 3 P. M. yesterda3^, when she became suddenly worse ; her respiration 
was short and gasping; she spoke, with an effort, in a whisper, but 
continued conscious ; and her pulse was strong. Death occurred at 
5 P. M., apparently from obstructed respiration. In the last days of 
her sickness there was but little pharyngitis, and little or no external 
swelling. 

Autopsy twenty-four hours after death. — Body a little emaciated ; heart 
large for a child of five years ; about one ounce of turbid serum in the 
pericardium ; a soft deposit of lymph within the pericardial sac at the 
base of the heart, around the origin of the great vessels evidence of 
recent circumscribed pericarditis ; from four to eight ounces of trans- 
parent serum in each pleural cavity ; no fibrin upon or opacity of the 
pleural surfaces ; mucous membrane of bronchial tubes injected in streaks, 
and muco-pus can be pressed from them ; both lungs can be readily in- 
flated, with the exception of small portions of both the lower lobes, 
which are hepatized, and can be but partially inflated; liver enlarged, 
presenting a congested appearance, and extending some four inches be- 
low the free border of the ribs ; upon its convex surface in the epigas- 
trium, corresponding with the seat of the pain, is a white rough patch 
of fibrin about one and a half inches in diameter ; kidneys congested ; 
stomach and small intestines apparently healthy; mesenteric glands 
moderately enlarged ; mucous membrane of transverse and descending 
colon somewhat injected and thickened, showing mild colitis; no ulcera- 
tion noticed; brain not examined. 

Microscopic examination was made of the blood, hepatized portions 
of lung, etc., but nothing of special interest in this connection was 
observed. 

This case is instructive as showing the liability which exists in 
and after scarlet fever to inflammations, and the difficulty of 
diagnosticating them in certain cases on account of their circum- 
scribed character. 

Sequels. — The complications described above may occur as 
sequelae, but there is another pathological state which may be 
a complication, and is a common and serious sequel. I refer to 
nephritis with albuminuria. This occasionally commences in sear- 
let fever, but usually not till the disappearance of the rash. There 
is sometimes, during the course of scarlet fever, and even subse- 



180 SCAELET FEVER. 

quently, slight albuminuria due to simple congestion of the kid- 
neys, but the albuminuria to which I allude, and which requires 
treatment, is more serious. Its anatomical character is as follows : 
hyperemia, and perceptible increase in volume of the kidneys ; 
proliferation of the renal epithelial cells like that of the epidermis, 
and a granular deposit in them ; the escape of albumen from the 
engorged capillaries, and its appearance in the urine ; the forma- 
tion of fibrinous casts in the tubuli uriniferi, these casts often con- 
taining more or fewer epithelial cells ; the escape of the casts from 
the kidneys with the urine ; diminution of amount of urea ex- 
creted, and, therefore, its accumulation in the blood ; and finally 
rupture of the engorged capillaries of the kidneys, and mingling of 
the elements of the blood with the urine. 

The presence, therefore, of this renal affection can be readily 
ascertained by examining the urine. The quantity of albumen 
which this liquid contains can be approximatively ascertained by 
adding nitric acid or applying heat. If the quantity is small, simple 
cloudiness is produced ; if large, the urine becomes thick and white, 
and in extreme cases almost semi-solid from coagulation of the albu- 
men. The character of the urine can, however, be more accurately 
ascertained by the microscope than by the tests which have been 
mentioned, since by it we discover the fibrinous casts, altered epi- 
thelial cells, and blood corpuscles. 

Nephritis, with the consequent ursemia, soon gives rise to evident 
symptoms. Serous effusion takes place in consequence of the altered 
state of the blood, the most common form of which is anasarca, 
occurring upon the face and limbs, and sometimes in the areolar 
tissue of the trunk. Often the effusion occurs only in the external 
areolar tissue, and the result is then favorable; but in other cases it 
occurs, and in the order mentioned as regards frequency, in the 
lungs (oedema pulmonum), serous cavities, and, lastly, in the submu- 
cous connective tissue of the larynx (oedema glottidis). The internal 
effusion should excite the gravest apprehensions, as it is often fatal. 
Fortunately, it is in most cases preceded as well as accompanied 
by anasarca, which is easily detected, so that there is sufficient 
forewarning. The fact of an occasional exception to this rule 
should be borne in mind. 

Scarlatinous nephritis, with consequent uraemia, is due to the 
direct effect of the scarlatinous poison on the kidneys. I have 
known it occur in the nurse who attended a child through the 
fever, but did not suffer from the fever herself. It sometimes occurs 
quite abruptly, and often when the patient has been progressively 



SEQUELAE. 181 

convalescing, and, perhaps, has seemed out of danger. In most 
cases, however, there are well-marked premonitory symptoms, as 
fever, restlessness, loss of appetite. The anasarca is first observed 
in the face or about the ankles. Sometimes it remains inconsider- 
able, but in other cases it increases day by day, more or less 
rapidly, till the appearance of the patient is much altered. In 
marked cases of anasarca the features are so bloated that their 
natural expression is lost. The volume of the trunk and legs 
is augmented, and, more slowly, that of the arms. In the male 
child the penis and scrotum frequently attain three or four times 
their normal dimensions, in consequence of serous infiltration. 

The duration of the anasarca or dropsy is very different in dif- 
ferent cases. If the form be oedema pulmonum, oedema glottidis, 
or intra-cranial effusion, death is speedy. It may occur even within 
a day. Hydrothorax and hydropericardium are also ordinarily 
fatal, though not so speedily; while in ascites the prognosis is 
much more favorable. The duration of anasarca under the most 
favorable circumstances, unless it is very slight, is commonly not 
less than two or three weeks, and is often much longer. There is 
another and an important source of danger apart from the serous 
effusions, namely, the retention of urea in the blood. Convulsions, 
coma, and death may occur from ursemic poisoning, as in Bright's 
disease. In those cases there is great and continued scantiness of 
urine, in consequence of obstruction in the tubuli uriniferi from 
fibrinous casts and granular and swollen epithelial cells. 

The liability to this renal affection is greatly increased, and in 
some cases is mainly attributable to the close relationship, as re- 
gards their functions, which exists between the skin and kidneys. 
A common exciting cause is exposure to vicissitudes of tempera- 
ture or currents of air, by which the surface is chilled, and cutane- 
ous transpiration checked, at the time when the old epidermis is 
being detached. The increased burden thrown upon the kidneys 
results in the pathological state which has been described. This 
remark does not conflict with the statement already made, that the 
nephritis is due to the direct effect of the scarlatinous principle on 
the kidneys, the disturbance of the function of the skin merely in- 
creasing the functional activity of these organs and rendering them 
more susceptible to the disease. All who have seen much of scarlet 
fever can recall to mind cases in which the patients had nearly 
recovered, when from some needless exposure in the streets, or by 
chilling of the body in a cold room, or open window, this affection 
occurred, with perhaps a fatal result. Elsewhere I have alluded 



182 SCARLET FEVER. 

to a case in which scarlet fever was only detected by this sequel, 
which began when the child was daily exposed in the open air. 
But many children who have been attended with the utmost care, 
and who, through the whole desquamative period, are kept in a 
uniform temperature, nevertheless become affected with albumi- 
nuria and dropsy, so that there is sufficient cause of this sequel in 
the state of the child and the nature of the disease through which 
he has passed, apart from extraneous influences. It is an interest- 
ing fact that albuminuria is more apt to occur after mild than severe 
cases of scarlet fever, and observations show that this difference in 
liability to albuminuria is intrinsic ; in other words, that it does 
not depend, as some have supposed, on a difference in the hygienic 
management of mild and severe scarlatina. 

The symptoms in scarlatinous nephritis vary not only according to 
the degree of the inflammation, but also according to the amount and 
seat of the effusion. I have stated that it usually commences with 
languor and more or less fever. The pulse remains accelerated, the 
skin is hot and dry, and the appetite poor. This affection, if slight, 
may occur without appreciable effusion, either in the cellular tissue 
or the cavities, but ordinarily in these mild cases a little puffiness 
is observed around the eyes or upon the extremities. In the 
majority of cases more extensive anasarca results. The skin is 
then pallid, distended, and pitting on pressure. The anasarca does 
not, in most instances, give rise to any marked symptoms. If 
oedema glottidis or pulmonum occur, the respiration becomes 
rapidly more embarrassed, till soon the blood is no longer suffi- 
ciently oxygenated for the purposes of life. The chief symptom in 
hydrothorax is accelerated and difficult respiration ; in hydroperi- 
cardium the symptoms are such as arise from embarrassed action 
of the heart ; in ascites there are either no marked symptoms, or, 
if the amount of liquid is large, there may be more or less embar- 
rassment of respiration from compression of the lungs. 

Otorrhoza. — Inflammation of the external ear, giving rise to 
otorrhcea, is a frequent sequel of scarlet fever. It sometimes 
commences as a complication in the last stages of the fever; at 
other times it begins during convalescence. It often produces a 
degree of deafness, which, in most instances, soon passes off. A 
thin, purulent discharge from the ear may remain for months or 
even years, and hence the name which designates this affection. 
In exceptional cases, internal otitis occurs. This is a more serious 
sequel ; it may impair the hearing permanently. There are cases 
in which not only the drum of the ear is destroyed, but the ossicles 



NATURE. 183 

are detached, and lost through the external ear. Complete deaf- 
ness then results. I have met one case, in which both ears were 
so injured by scarlet fever in infancy, that the child grew up a 
mute. The result is sometimes still more serious. The inflamma- 
tion may extend inwards, causing caries of the petrous portion of 
the temporal bone, till it reaches the lateral or petrosal sinuses. 
The inflammation then causes thickening and bulging of the 
walls of the sinuses, and, consequently, partial obstruction to the 
circulation, congestion in the veins and sinuses, the formation of 
thrombi, and finally coma and death. Fortunately, this melan- 
choly termination of scarlatinous otitis is not frequent. 

Anatomical Characters. — There is some difficulty in determin- 
ing what are the anatomical characters of scarlet fever, since so 
many who die of this disease have a complication, and the lesions 
of this are superadded to those of the fever. The following, how- 
ever, are the facts which have been ascertained in reference to 
this point. In many the brain, its membranes, and the lungs are 
congested; often, also, the Peyerian, solitary, and mesenteric glands 
are enlarged, and the spleen enlarged and softened. The liver and 
kidneys do not present any notable alteration, though the latter 
are so often affected during the period of convalescence. Dr. 
Samuel Fenwick {London Lancet, July 23, 1864) has made post- 
mortem examinations in sixteen cases of scarlet fever, and concludes 
from them that there is inflammation of the mucous membrane of 
the stomach and intestines like that of the skin, and that there is 
desquamation of the epithelial cells from those portions of the 
digestive tube like that of the epidermis. I have had opportunity 
of examining the stomach and intestines in those who died in 
the eruptive stage during epidemics, in the Nursery and Child's 
Hospital, and have never found any unusual hyperemia of the 
gastro-intestinal surface, unless when gastro-intestinal inflammation 
had occurred as a complication. In malignant cases the blood is 
dark, and the heart-clots soft and small ; in other cases the color of 
the blood may be nearly normal, and the heart-clots of the usual 
size and firmness. 

Nature. — Scarlet fever presents in a marked degree the distin- 
guishing features of the contagious affections. It is highly infec- 
tious ; it is also inoculable. Stoll, d'Amboise, and others successfully 
inoculated with the scarlatinous virus, using the blood, but without 
diminishing the intensity of the disease. "Whether scarlatina ever 
originates spontaneously is uncertain; but if it do, such cases are 
rare. It ordinarily spreads through a community by infection, 



184 SCARLET FEVER. 

though the distance to which it is infectious is short, probably not 
more than two or three yards. Some consider the distance to be 
even less than one yard. Knowledge of this fact is important, 
as by isolating in a family a child attacked by scarlet fever, and 
allowing no communication with the nurse, the other children 
often escape. A very common mode of communication is by 
clothing, so that a third person is the medium of transmission. I 
have noticed that when scarlet fever, as well as measles, is epidemic 
in this city, a large proportion of the cases, nearly all, indeed, of 
the first cases, can be traced to the public schools. Exposure occurs 
through those children who come from apartments where cases are 
under treatment. Physicians, and especially nurses, are sometimes 
the medium of communication. A medical friend of mine went 
directly from some children with scarlet fever, whom he was 
attending, to another family, where he took a little girl upon his 
knee. This girl in a few days became affected with scarlet fever 
and died. The two remaining children in the family were then 
attacked, and one died. Murchison alludes to similar cases {London 
Lancet, August 13, 1864). In one instance in my practice scarlet 
fever was communicated to an infant by a washer-woman whose 
own child had the disease, and who, on reaching the house where she 
had been engaged to work, threw her shawl over the cradle where 
the infant was sleeping. Six days later the infant was attacked. 
Mason Good cites a case where a box of toys was the medium of 
communication; and it is said that also a letter has been. The 
scarlatinous virus may remain for weeks and even -months in 
apartments, clothing, or in or upon the person of one who has 
been affected, without any appreciable diminution in its effective- 
ness. A physician of this city, in whose family scarlet fever 
occurred, excluded a child from the room occupied by the patients, 
and from the patients themselves, for a month after the last case 
occurred, and yet, although precautions had been taken in reference 
to clothes and bedding, this child was taken with scarlet fever soon 
after it was allowed to mingle with the other children. The father 
believes that the exposure was through the otorrhoea of one of the 
children. Observations, indeed, appear fully to establish the fact 
that the discharge from the ear or nostrils, and the particles of 
epidermis which have exfoliated, may retain the virus and be the 
medium of communicating the disease several weeks after the fever 
has terminated. In a case in my practice a little girl returned 
home six weeks after her brother had scarlet fever, and, within a 
few days, took the disease. A more striking example occurred 



NATURE. 185 

in the practice of Dr. Kearney Rogers, formerly a prominent and 
much esteemed surgeon of this city, and was related to me by an 
intelligent friend of the family since the doctor's death. Six 
children in a family had scarlet fever. Three and a half months 
subsequently another child, living at a distance, was allowed to 
visit them in the apartments where they had been sick. One week 
from that day this child became affected with the disease. Dr. 
Elliotson states that a patient with scarlet fever was admitted into 
one of the wards of St. Thomas's hospital, and, for two years 
subsequently, young persons who were admitted into this ward 
were apt to take the disease. Dr. Richardson relates the case of a 
family of four children, residing in the country. One died of 
malignant scarlet fever, and the rest, who had been removed, 
escaped. Some weeks subsequently one of the children returned, 
but within twenty-four hours took the disorder and died. The 
cottage was now thoroughly cleaned, whitewashed, and the clothing 
destroyed. Four months then elapsed, when the third child returned 
home, who also took scarlet fever in a malignant form and died. 
It was believed that the virus remained attached to the thatch, 
which extended close to the children's bed. Other similar examples 
might be mentioned, sufficient to establish the fact of the great 
permanence of the scarlatinous virus. 

The period of incubation in scarlet fever varies. It is seen in 
the remarkable example of contagion, given above, that it was only 
twenty-four hours. Trousseau also relates an interesting example 
of short incubation. " An English gentleman with his daughter 
was returning from Pau to London, and was joined at Paris by 
another daughter, who came direct from London. Scarlet fever 
was prevalent in London, but there was not a case of it at Pau. 
The second daughter was seized with scarlet fever in crossing the 
channel, and joined her relatives in Paris seven or eight hours later. 
She occupied the same room in the hotel as her sister, who was 
also attacked within twenty-four hours." The incubative period 
is, however, seldom so short. It is usually from three to eight 
days. I might cite several cases in which this was its duration. 
Some writers allude to cases in which two, three, or even four 
weeks elapsed from the time of exposure to the appearance of the 
disease. It is, however, a question whether in such cases there 
may not have been a second and more recent exposure. Rostan 
alludes to cases in which scarlet fever was communicated by inocu- 
lation, and in which the period of incubation was seven days. 

Scarlet fever occurs most frequently between the ages of three 



186 SCARLET FEVER. 

and ten years. It is infrequent under the age of one year, and 
infants under the age of three months may be considered safe from 
an attack of it, though fully exposed. Cases have been reported 
of scarlet fever occurring in the foetus, and manifesting itself by 
the usual signs at birth. But a clear diagnosis in such instances 
is necessarily difficult, on account of the character of the scarla- 
tinous eruption on the one hand, and the nature of the cutaneous 
circulation in the newly-born on the other. It is probable that, in 
the cases alluded to, there was an error of diagnosis. Certainly in 
two instances I have known women immediately after their con- 
finement (within a week) take scarlet fever, and although they 
communicated the disease to others, did not to their infants. 
Murchison states that twice he has known women with scarlet 
fever to be confined, and in both instances the infants were healthy. 

Most adults possess immunity from scarlet fever, although not 
protected by an attack of it in childhood. Parturient women, 
however, are liable to it, and there is considerable danger that the 
physicians who attend them, if at the same time visiting cases of 
scarlet fever, may communicate the disease to them. 

Scarlet fever is sometimes sporadic, but, as we meet it in this 
country, it occurs most frequently as an epidemic. The epidemics 
vary greatly in type. Some are mild, and attended by few com- 
plications, so that the result of treatment is eminently satisfactory. 
In other epidemics the type is malignant, the complications fre- 
quent, and the percentage of deaths large. There is sometimes a 
succession of epidemics of one type, and then the character of the 
disease changes. This fact of a variable type is important as re- 
gards the value of statistics relating to treatment. Each epidemic 
has its prevailing character, but when the form is mild, there is 
now and then a case of severity, and when it is malignant, now and 
then one of unusual mildness. The epidemic influence is some- 
times manifested in those exposed to scarlet fever by the occurrence 
of pharyngitis, and, as we have seen, nephritis. Professor George B. 
Wood, of Philadelphia, says {Treatise on the Practice of Med.): " I 
seldom attend cases of scarlet fever without having sore throat." 

Scarlatina usually occurs but once in the same individual, but a 
second attack after the lapse of several years is not uncommon, and 
there are even cases on record of a third attack. But physicians 
sometimes mistake roseola or erythema for scarlet fever, and, 
though afterwards aware of their mistake, do not correct their 
diagnosis. Hence there is a belief in the community that second 
attacks of scarlet fever are more frequent than they really are. 



DIAGNOSIS. 187 

Diagnosis. — In the commencement of scarlet fever, prior to the 
eruption, there are no symptoms or appearances which will enable 
us to make a positive diagnosis. Positive statement in reference 
to the nature of the disease might better be deferred, for the credit 
of the physician. Still, if a child with regular bowels, and no 
appreciable local disease, a few days after exposure to scarlet fever, 
is suddenly seized with intense fever, the pulse rising to 110, 120, 
or more, and the temperature to 102°, 103°, or 105°, there is little 
doubt that the disease is scarlet fever. The diagnosis is rendered 
more certain if there is vomiting, and especially if, as is often the 
case, there is, at this early period, a blush of redness upon the fauces. 

When the eruption has appeared, the nature of the affection is, 
in most cases, apparent. Still, roseola or erythema, due to intes- 
tinal derangement or other causes, has often, as already stated, 
been mistaken for scarlet fever. A day or two suffices to show the 
error. In scarlet fever there is more inflammation of the faucial 
and buccal surface, more continuous and persistent redness of the 
skin, and greater intensity and persistence of symptoms, than in 
those diseases. Scarlet fever is also further distinguished from 
them by the papular elevations upon the tongue, and the minute 
papulae upon the skin. Besides, in scarlet fever, except in the 
mildest cases, there is from the first the aspect of serious sickness, 
which roseola and erythema do not present. 

Scarlet fever and measles were long considered identical by the 
profession, and, though the ordinary forms of the two diseases can 
be readily distinguished from each other, there are instances in 
which the differential diagnosis is attended by some difficulty. 
Measles occurring in a robust child, with an active cutaneous cir- 
culation, sometimes presents a continuous eruption over a consid- 
erable part of the surface, like the eruption of scarlet fever. But 
the longer period of invasion, the coryza and bronchitis, and the 
absence or slight degree of pharyngitis, in connection with other 
symptoms, enable us to distinguish these cases from scarlatina. 
Moreover, in those cases of measles in which there is continuous 
redness of surface where the circulation is most active, as upon the 
face, the characteristic rubeolous eruption is present in other parts, 
so that, with care in examination, error of diagnosis may be avoided. 
Scarlet fever and measles may indeed occur together, but such a 
complication is rare. 

The greatest difficulty of diagnosis occurs in abnormal scarlatina, 
especially when the rash is partial and indistinct. There is apt to 
be, in this form of the disease, an inflammatory complication, which 



188 SCARLET FEVER. 

causes withdrawal of blood from the surface, and it is sometimes 
very puzzling to decide whether this is a complication, or the sole 
disease. The points involved in diagnosis are numerous, but they 
are sometimes not sufficient to show the character of the affection. 
G-enerally, however, by observing the clinical history from day to 
day, the diagnosis is established. In cases of doubt it is safest to 
adopt such hygienic management as is appropriate to scarlet fever. 

Prognosis. — The prognosis depends on the form of the disease, 
whether mild or severe, the presence or absence of complications, 
and the strength of the patient. The mortality varies greatly in 
different epidemics. In epidemics of a mild type, the mortality is 
sometimes not more than one in twelve, and the ratio may be less ; 
whereas, if a severe form is prevailing, not more than one recovers 
in every two, three, or four. The mortality is greater in the city 
than country, in hospital than in private practice. Rilliet and 
Barthez, in hospital practice, lost forty-six out of eighty-seven. 
Scarlatina is, of itself, less fatal than statistics would lead us to 
suppose, since a large proportion of those who die in consequence 
of it die from complications or from sequelae, rather than from the 
primary disease. 

The symptoms, in the first days of scarlet fever, which indicate 
an unfavorable termination, are convulsions, except at the very 
commencement, great drowsiness, with jactitation, great elevation 
of temperature, a rapid pulse, duskiness of the eruption, and feeble 
capillary circulation. At a later period, particularly in the second 
week, other unfavorable symptoms may occur in malignant and 
fatal cases. Violent pharyngeal inflammation, with great external 
swelling from the adenitis and cellulitis, is apt to be present at 
this stage of the disease. Severe inflammation of this character, 
as indicated by the tumefaction, greatly increases the danger. 

As there are several complications and sequelae of a dangerous 
character, and as these are apt to occur suddenly, and often without 
appreciable existing cause, in mild as well as severe cases, it is 
unwise ever to make an unconditional favorable prognosis. The 
patient is not to be considered entirely safe till two or three weeks 
have elapsed after the eruption. 

Some patients who have passed through scarlet fever, die of 
asthenia, in consequence of the anaemic state which the fever has 
produced. They have not sufficient vigor of system to recover, 
although no serious complication or sequel has occurred. In other 
cases the pharyngitis and cellulitis, attended with tumefaction, 
rendering deglutition painful, and keeping up the febrile movement 



TREATMENT. 189 

after the primary disease has run its course, have much to do in 
producing a state of exhaustion and death. But the mortality in 
the desquamative stage, and subsequently, is more frequently due 
to the renal affection, which is so common, than to any other cause. 
This affection gives rise to dropsies, which are fatal, or to ursemic 
convulsions, and coma. Sudden and unexpected deaths are not 
uncommon in scarlet fever, and it is probable that, in many of 
these cases, the immediate cause is uraemia, which, not having 
produced any conspicuous symptoms till near the close of life, is 
not discovered. 

Treatment. — Scarlet fever, when mild, and without complica- 
tion, requires little treatment. A gentle cathartic, like the citrate 
of magnesia, should be given from time to time, if there is a 
tendency to constipation, and a simple diaphoretic mixture in 
addition, is all that the case requires. 

R. Spts. aether, nitr., 
Syr. ipecac, aa 5ij ; 
Syr. simplic. 3J. Misce. 
Dose, one teaspoonful every three hours to a child of three to five years. 

If there is restlessness, an occasional warm mustard foot-bath 
will give relief; and if there is considerable fever, as indicated by 
flushed face, heat of head, cephalalgia, or other nervous symptoms, 
cool applications should be made to the head, and the face and 
forehead occasionally bathed with cool water, bay rum, or other 
cooling lotion. The mildest cases indeed commonly do well with- 
out treatment, except hygienic, though it may be necessary, in 
consequence of the impatience of the family, to prescribe a placebo. 
When the fever has begun to abate, in such cases, if the appetite 
returns, and there is no complication, and no symptom of feeble- 
ness, there is little for the physician to do. But if, as is sometimes 
the case, even when the disease has been mild, the appetite remains 
poor, and the aspect is anaemic, tonics are required, especially 
chalybeates. 

The majority of cases, however, demand more decided measures 
than those described above. We pass to the consideration of cases 
of moderate severity, and those of a grave character. Trousseau 
recommends cold affusions as an important part of the treatment. 
They should be employed in the first stages of sthenic cases. They 
are especially beneficial, it is stated, in those cases in which nervous 
symptoms predominate. The patient is placed naked in a bathing- 
tub, and three or four pails of water are thrown over him, in a 
space of time varying from a quarter of a minute to one minute, 



190 SCAELET FEVER. 

after which he is covered with bedclothes, without being wiped. 
Reaction immediately occurs, often with more or less perspiration. 
This treatment is repeated once or twice daily, according to the 
gravity of the symptoms. 

" Dr. Currie," says Trousseau, " was the first who made use of 
this treatment, and he established its applicability, as a general 
rule, in scarlatina accompanied by grave nervous accidents, such as 
delirium, convulsions, diarrhoea, excessive vomiting, considerable 
exaltation of the heat of surface." Trousseau believes that cold 
affusions diminish the febrile movement, and calm the nervous 
excitement, and he further adds : " * * I have never adminis- 
tered it without deriving some benefit." Public opinion is, how- 
ever, so averse to such treatment of the eruptive fevers, that one 
of less authority than Trousseau would scarcely be able to employ 
it. The shock of such treatment to a child not sufficiently old to 
be reasoned with must be considerable, and it would seem question- 
able whether the excitement from such a measure may not increase 
the liability to clonic convulsions. 

In the cases alluded to by Trousseau, in which there is great heat 
of surface, and nervous symptoms predominate, though cold affu- 
sions are not used, there is no doubt of the beneficial effect of cold 
applications to the head, and sponging the face and arms. This may 
be frequently repeated if there is great elevation of temperature. 

The medicinal treatment of scarlet fever has varied greatly at 
different periods, according to the theory which happened to pre- 
vail, and it is even now far from uniform. Physicians, however, 
generally prescribe sustaining measures. If catalysis occur, as the 
fundamental pathological process, in scarlet fever, and the other 
so-called zymotic diseases, and if we possess safe anti-catylitic 
medicines, which will arrest this process, these agents are in all 
cases required. But the use of anti-catylitics is still experimental, 
and they are not, therefore, to be recommended in place of remedies 
which have been long employed, and are known to be of real value. 

Depletion is rarely required in scarlet fever ; on the other hand, 
sustaining measures are indicated from the first. Bloodletting, 
formerly more or less employed in the treatment of this disease, 
is now almost obsolete. In no instance is venesection required. 
In rare instances, in robust children, having an active circulation 
and a decidedly sthenic form of the disease, there might be a con- 
dition in which one or two leeches would be serviceable ; as, for 
example, leeches applied to the temple, if there is evidence of 
dangerous cerebral congestion. But in these cases a sufficiently 



TREATMENT. 191 

sedative or tranquillizing effect can, ordinarily, be produced by 
the application of cold to the head, cold ablutions to the face and 
hands, and by an occasional warm general or foot bath. In all 
malignant cases, measures which reduce the vital powers cannot 
fail to be injurious. In those cases which are properly designated 
by that name, there are often evidences of prostration from the 
first, as drowsiness, jactitation, delirium, languid circulation, 
evinced by the dusky hue of the surface. These symptoms indi- 
cate the need of stimulants. 

In the ordinary as well as severe forms of scarlet fever, carbonate 
of ammonia, administered with a tonic, is one of the best remedies. 
It is, moreover, recommended by the best authorities. It may be 
prescribed at the first visit of the physician, and continued at 
regular intervals. It is used as a main remedy by many judicious 
and skilful practitioners. I ordinarily prescribe it in combination 
with citrate of iron and ammonia. 

R. Ammon. carbonat., 

Ferri et ammon. citrat., aa ^ss; 
Syr. simplic. ^ij. Misce. 
Dose, one teaspoonful every three hours to a child of fire years. 

The preparations of cinchona are also useful tonics. The reader 
is referred to our remarks on the use of carbolic acid, under the 
head of Prophylaxis. It promises to be not only a prophylactic, 
but remedial agent of great value in scarlet fever. 

An unpleasant symptom in most cases, and one which increases 
greatly the restlessness of the patient, is itching of the skin. The 
safest and best remedy for this is inunction. Fresh lard has 
sometimes been employed for this purpose. It relieves the dry- 
ness, and in a measure the heat of surface, and at the same time 
diminishes the itching. The odor from the lard is, however, 
offensive after it has been used for a day or two. An equally effica- 
cious, more agreeable, but more costly substance for the inunction 
is glycerine, which may be applied pure, or scented with one of 
the essential oils. Dr. J. F. Meigs recommends the following : — 

R. Glycerinse 3J ; 

Ung. aq. rosce §j. Misce. 

I prefer to either of these applications the employment of sweet 
oil or glycerine, to each ounce of which about six or eight drops of 
carbolic acid are added. 

The inunction should be made with the palm of the hand, or with 
muslin or linen. Those parts of the surface which are the seat of 



192 SCARLET FEVER. 

itching should be frequently treated in this way, and occasionally 
the application may be made over the entire surface. Eot only 
does inunction have the local effect which has been described, but 
it is stated to diminish sensibly the rapidity of the pulse and the 
general temperature of the body. 

The cases which require the closest watching and the most judi- 
cious management are those of an ataxic character. These cases 
are characterized by nervous symptoms, as jactitation, drowsiness, 
delirium. There is great heat of surface, while the capillary 
circulation is sluggish. Sometimes the rash is indistinct. In such 
cases a general warm bath is useful, to which mustard is added in 
sufficient quantity to cause some irritation of the surface. This 
not only quickens the capillary circulation, producing a better 
color of the rash, or causing it to appear, if its development is 
retarded, but it calms the nervous excitement, and is often instru- 
mental in preventing convulsions. If convulsions occur, which 
are attended by disappearance of the eruption, the bath should be 
employed at once. In grave cases, in which the rash is indistinct, 
some physicians, whose opinions are entitled to consideration, em- 
ploy belladonna in sufficient dose to cause an eruption. I am not 
aware, however, that the severity of scarlet fever is diminished by 
this agent, as thus employed, although the disease is apparently 
rendered more normal by its use, so far as the rash is concerned. 

The pharyngitis demands attention in most patients. Various 
modes of treating this have been recommended. The application 
of leeches to the throat, once a common practice in severe scar- 
latinous pharyngitis, has fortunately fallen into disuse. If the 
pharyngitis might be diminished by leeching, which is doubtful 
for this form of inflammation, the benefit is more than counter- 
balanced by the evil effect, as regards loss of strength, which 
results from depletion. The application to the throat of a cloth 
wrung out of cold water, or containing pounded ice, has been 
recommended; but the continued wetting of the patient which 
such treatment necessitates, and the danger from constant cold 
applications of chilling the body and causing retrocession of the 
eruption, would deter the prudent practitioner from employing 
such measures. 

After making use of various applications, I have been led to 
regard with most favor the use of a slice of salt pork, cut as thin 
as possible, and stitched to a single thickness of muslin or linen. 
The pork should pass from ear to ear, the cloth being tied or 
pinned over the vertex. It is best to sprinkle salt, or salt and 



TREATMENT. 193 

pulverized camphor, upon the pork, in order to secure a more 
prompt effect. If the application is properly made, the surface 
usually begins to he reddened in twenty-four hours, and, by the 
second day, an impetiginous eruption appears upon the part cov- 
ered by the pork. Counter-irritation gradually produced in this 
manner causes little suffering. Patients, ordinarily, do not com- 
plain of it at all. This application should be continued through 
the fever, being occasionally left off for a day or two, as too much 
soreness is produced, and a linen cloth smeared with sweet oil or 
some simple ointment applied in its place. 

This simple external treatment diminishes the inflammation 
of the mucous membrane underneath, and also to a certain extent 
that of the connective tissue, in those severe cases complicated 
with cervical, cellulitis so that tumefaction and suppuration about 
the angle of the jaw are less likely to occur. A well-known physi- 
cian of this city, who has had ample experience in the treatment of 
children's diseases, ordinarily applies a small blister over the most 
prominent part of the swelling at the earliest moment, and by the 
vesication believes that he often succeeds in materially diminishing 
the inflammation. But counter-irritation in the manner which I 
have advised has the advantage of being less painful while it is 
equally effectual, and the irritated surface heals readily. I have 
never known the eruption produced by pork assume a gangrenous, 
phagedenic, or otherwise unhealthy appearance. This treatment 
does not always prevent a considerable degree of inflammation and 
tumefaction, but, if properly employed, it does diminish more or 
less this local affection. If there is external swelling which 
counter-irritation does not remove, and it becomes red and painful, 
irritating applications are no longer proper. Emollient poultices 
are now required. 

Mild cases of scarlet fever do not require direct applications to 
the inflamed faucial surface. Gargles of a saturated solution of 
chlorate of potash, to which one of the astringent preparations, of 
iron is added, or, better, carbolic acid in the proportion of about 
six drops to the ounce, should be employed by those old enough to 
use them, in cases of moderate or severe pharyngitis. In younger 
children, and in all cases in which the pharyngeal symptoms are 
urgent, we cannot rely on gargles, but must make direct applica- 
tions to the throat with a probang or a large camel's-hair pencil. I 
advise, in such cases, the application every three or four hours of 
the carbolic acid and chlorate of potassa, directing, also, the nos- 
trils to be syringed with the same three or four times daily : — 
13 



194 SCARLET FEVER. 

R. Acid, carbolic. 5 s s; 
Potas. chlorat. 3iij ; 
Glycerinse §ij ; 
Aquae ^iv. Misce. 
For the throat. 

The effect of carbolic acid in checking the muco-purulent dis- 
charge and relieving the inflammation is often very decided. Occa- 
sionally, in severe cases, I apply once or twice daily in addition — 

R. Liq. ferri subsulphat. 5j ; 
Glycerinse 3iij. Misce. 

There is no application more effectual than this in removing any 
pseudo-membrane, and by its powerful astringent effect diminish- 
ing the turgescence of the inflamed surface. Yeast is also useful 
in many of these cases, given in the quantity of half a teaspoonful 
to a teaspoonful several times daily. As it is swallowed it touches 
each part of the throat, and, if no drink is allowed for a few minutes 
afterwards, it produces a healthy, stimulating effect on the dis- 
eased surface. 

Sometimes, in feeble children, viscid mucus collects in the 
pharynx and around the aperture of the glottis, so as to interfere 
with inspiration. In these cases there is danger of death from 
apncea. Prompt interference is required. Swabbing the throat 
removes the mucus, which is attached to the swab, or is expecto- 
rated by the forced cough which the operation causes. The swab- 
bing may be performed by a piece of whalebone, bent at the end 
and wound with linen or soft muslin. I usually employ it dipped 
in the solution of carbolic acid and chlorate of potash. I have 
sometimes relieved the most urgent dyspnoea by this means. An 
accumulation of mucus in the pharynx or larynx, so as to require 
mechanical interference, is most frequent in infants. 

The diet in scarlatina should be nutritious, consisting of animal 
broths, milk porridge, and the like. The patient will rarely take 
solid food, except in the mildest cases. Those affected with grave 
forms of the disease require nutriment as regularly, night and 
day, as in typhus and typhoid fevers. 

In mild cases, alcoholic stimulants are not required, unless in 
moderate quantity towards the close of the disease. In severe 
cases, attended from the first with great prostration, they are 
needed throughout the entire course of the fever. Wine-whey 
or milk-punch should be regularly administered, in quantity ac- 
cording to the age of the child. The presence of severe nervous 
symptoms, as jactitation or delirium, in these asthenic cases, should 



TREATMENT. 195 

not deter from its employment. Convulsions and coma are, indeed, 
less likely to occur if stimulants are used, since the scarlatinous 
virus is, in a measure, counteracted by such agents. The apart- 
ment in which the patient is treated should be airy, and ventilated 
without exposure to currents of air. The temperature of the room 
should be uniform, about 68° for robust children with high fever, 
about 70° for feeble children. It should be a little more elevated 
after the fever has abated, and the desquamative period com- 
menced, than during the fever. The patient is, indeed, especially 
liable to be affected by changes of temperature, and currents of air, 
in the two or three weeks succeeding scarlet fever, and this expo- 
sure is very apt to result in inflammations, such as have been de- 
scribed. ' Therefore great care should be exercised in reference to 
the hygienic management of the patient during convalescence. 
In stormy weather he should be kept in-door for a month or six 
weeks. 

The nephritic affection which is so common a sequel of scarlet 
fever is often more dangerous than the primary disease itself. A 
clear appreciation of its therapeutic indications is important, since 
by judicious treatment many recover whose lives would inevitably 
be sacrificed by improper measures. As there is in these cases 
active hyperemia of the kidneys, having in most cases an inflam- 
matory character, diuretics which stimulate these organs should 
not ordinarily be given, at least till this pathological state has, in 
a measure, abated. As the eliminative functions of the skin and 
of the intestinal mucous surface are to a considerable extent vica- 
rious with that of the kidneys, diaphoretic and purgative remedies 
are required. By free diaphoresis, the ill effect of arrested or 
diminished renal secretion is, for a time, averted. Treatment to 
produce diaphoresis should vary somewhat in different cases. It 
should in most patients be commenced by the use of a warm general 
or foot bath, and the patient then be covered in bed. If free per- 
spiration is not produced, it may be promoted by placing against 
the patient one or more bottles of hot water, surrounded by a wet 
cloth. The steam arising from this, and enveloping the body and 
limbs, produces a prompt sudorific effect. There is in use in this 
city, in the treatment of these and similar cases requiring diapho- 
resis, a convenient apparatus for generating steam. It consists of 
a cylinder pierced with holes for the admission of air, and con- 
taining a spirit-lamp over which is a pan or pail holding a little 
water. The patient, nearly denuded, is placed in a chair, with the 
apparatus by his side, and is covered with a blanket so that the 



196 SCARLET FEVER. 

steam surrounds the body. This gives rise to free perspiration, 
which continues after the patient is placed in bed. This treatment 
may be repeated each day, if the patient require it, while diapho- 
retics or cathartics are given. 

The diaphoretics which are most serviceable in this affection are 
the acetates of ammonia and potassa, the bitartrate and citrate of 
potassa. Spiritus setheris nitrici, combined with either of these, 
increases the effect, if the surface is warm, especially if there is 
already diaphoresis from the bath or steam. Spiritus Mindereri 
may be given to a child of five years, in doses of two teaspoonfuls 
every two or three hours, either alone, or in combination with sweet 
spirits of nitre, as in the following formula : — 

R. Spts. aether, nitrici ^ss ; 

Liq. amnion, acetat. ^iv. Misce. 

The acetate of potash is a more agreeable medicine, and it is 
generally quite as effectual. It should be given, dissolved in water 
or syrup, in doses of about one grain for each year of the child's 
age. Whatever diaphoretic is used, has more effect, as has already 
been stated, if given in connection with the external measures 
designed to produce diaphoresis, which have been described above. 
If perspiration is not produced, the action of the medicine is proba- 
bly on the kidneys ; and if diuresis do not result, there is danger 
that the hyperemia of the kidneys will be increased. In such cases 
diaphoretics should be omitted, and cathartic medicines given in 
place ; or, if there is much exhaustion, it is sometimes better to 
give no eliminative medicine, and to treat the renal affection mainly 
by local and external measures. 

In robust children suffering from scarlatinous uraemia and serous 
effusions, no medicines afford so much relief in the commencement 
as cathartics of a hydragogue nature. A mixture of jalap and 
cream of tartar, pulvis jalapse compositus of the pharmacopoeia, 
meets the indication. Even in children somewhat reduced, medi- 
cines of this nature are often required. Cathartics are more certain 
in their effects than either diaphoretics or diuretics, and therefore 
they should be given in urgent cases in which it is necessary to 
remove the urea or serum as speedily as possible. An excellent 
prescription in many of these cases, and one from which I have 
obtained a good result, is the following : — 

R. Podopliyllin gr. j ; 

Sacch. alb. ^j. Misce. 
Divid. in chart, no. viii-xii. 
Dose, one powder, according to circumstances. 



TREATMENT. 197 

"When cathartic or laxative agents have been used two or three 
days, the kidneys, being less congested in consequence of the diver- 
sion that has occurred, often begin to excrete more freely. Sub- 
sequently to the employment of medicines of this kind, or in con- 
nection with them, diaphoretics are in most cases required. The 
physician's experience, and his discrimination in reference to the 
condition of the patient, will guide him in the selection of proper 
remedies to meet the indications. 

In a large proportion of cases, when this renal affection has 
continued one, two, or three weeks, the treatment which has been 
recommended above is no longer appropriate. There may be more 
or less anasarca and albuminuria, but the patient is anaemic, and 
evidently in need of sustaining measures, while there are no symp- 
toms which indicate immediate danger from retention of urea or 
the excess of liquid in the system. In these cases the tincture of 
the chloride of iron is a most useful medicine. "While it serves as 
a tonic, it seems also to have a diuretic effect. To a child of five 
years it should be given in doses of five drops, every three or four 
hours. 

If the patient is decidedly ansemic and feeble when the renal 
affection commences, and the symptoms are not urgent, it is best 
not to administer diaphoretics and cathartics, or to administer 
them sparingly, and to commence early with sustaining remedies. 
Cases like the following from my note-book are not infrequent. A 
little boy, pale and scrofulous, began to have anasarca, after scarlet 
fever, chiefly of the scrotum, and accompanied by a moderate de- 
gree of ascites. The urine, which was passed in nearly the normal 
quantity, contained albumen. This patient gradually and fully 
recovered, with no treatment except the use of an oil-silk jacket 
over the kidneys and abdomen, to promote diaphoresis, and the use 
of iron. Such a case actively treated by eliminatives would, proba- 
bly, have proved fatal. Uniform treatment for scarlatinous nephri- 
tis is therefore injudicious ; considerable variation in measures is 
demanded, according to the state of the patients. 

The otorrhoea of scarlet fever should not be neglected. It is apt 
to continue for months unless treated, and the hearing may become 
permanently impaired. There is danger, indeed, that the inflam- 
mation may extend inwards, with a most disastrous result. For 
this ailment there is, in my opinion, no remedy so useful as the 
following, which should be either dropped or syringed into the 
ear three times daily : — 



198 SCARLET FEVER. 

]$.. Acid, carbolic, gss-j ; 
Glycerine gij ; 
Aquae |iv. Misce. 

It is also very beneficial when the otorrhoea occurs from scrofula 
or other cause. When the remedial agents required for the fever 
are discontinued, and the otorrhoea persists, cod-liver oil and the 
syrup of the iodide of iron, given in appropriate doses, will often 
be found useful, not only for the general health, but the otorrhoea. 
(See Lond. Lancet, Dec. 3, 1870.) 

It is evident, from what has been said, that every possible pre- 
caution should be taken to prevent the patient's catching cold 
during the period of convalescence. He should not be allowed to 
go in the open air in unpropitious weather till a month after the 
fever. An oil-silk protection of the body, worn from the time 
that the febrile symptoms begin to decline, and covering the lumbar 
region, diminishes, in my opinion, the liability to nephritis and 
uraemia. 

Prophylaxis. — Since the period of Jenner's discovery of the pro- 
phylactic power of vaccination, as regards smallpox, the attention 
of the profession has been frequently directed to the prevention of 
scarlet fever. A medicine has been sought which would antago- 
nize and mollify, if not entirely prevent, the disease. Of late years 
it has been claimed that belladonna, given during the period of 
exposure, and subsequently, is a preventive. The first employment 
of this agent for such a purpose was based entirely on theoretical 
grounds, it being presumed that, as it produces an eruption of the 
skin and dryness of the throat, like those of scarlet fever, it is there- 
fore antidotal. Whether or not belladonna does have such an effect 
can only be determined by experience, and latterly, as observations 
accumulate, the number does not seem to increase of those who be- 
lieve in its prophylactic power. Still, there is difference of opinion 
among good observers. The difficulty of determining positively 
the matter of prophylaxis is apparent when we consider that many 
children who are exposed to scarlet fever do not take it, although 
nothing is done for the purpose of prevention. Burnett made use 
of the following prescription as a preventive : — 

$. Ext. bellad. gr. j ; 

Aq. canellse gij. Misce. 

Two or three drops were given morning and evening to a child 
of one year, and one drop more for every year for children of a 



TKEATMENT. 199 

more advanced age. He administered it to 120 infants, of whom 
only five contracted the disease. Schenck, half a century since, 
stated that, in the course of an epidemic, out of 525 persons who 
took belladonna only three contracted the disease. M. Biett, whose 
observations were made during the epidemic prevalence of scarlet 
fever in Switzerland, states that those to whom belladonna was 
given usually escaped. On the other hand, Lehmann and Wagner 
may be mentioned among others on the continent, who believe 
that they have derived no benefit from the use of this medicine. 
These physicians have seen one-fourth to one-third of those to 
whom belladonna had been given take scarlet fever. In this 
country, observers differ in their estimate of the preventive effect 
of belladonna. Dr. Irwin, of South Carolina, as quoted by Dr. 
Condie, gave it to 250 children, and less than half a dozen took 
the affection. He employed a solution of three grains of the ex- 
tract in an ounce of cinnamon-water, giving two or three drops to 
a child under the age of one year, and one additional drop for each 
year. Dr. Condie himself, however, has had a different experience. 
He has prescribed belladonna, " but, although redness and dryness 
of the throat, and a diffuse scarlet efflorescence, were produced in 
the majority of cases, we never," says he, " found it in any to exert 
the slightest influence in mitigating the character or preventing 
the occurrence of scarlatina. The experiments were made during 
the prevalence of the disease, and in numerous instances the sub- 
jects of them were attacked. In one case the efflorescence was 
kept up by the use of belladonna forty-eight hours. In a week 
afterwards this individual took the disease in its most violent form, 
and died on the fourth day." My observations in reference to this 
use of belladonna are few, and they are not at all favorable to its 
employment. I have known scarlet fever occur, without appa- 
rently any modification, though belladonna was administered daily. 
Those who have made trial of this medicine have administered it 
in very different doses. Hahnemann employed it in so small a 
dose, that it would seem, a priori, that it could have had no effect. 
Hufeland employed the following formula : — 

]$. Ext. bellad. gr. iij ; 
Alcohol £j ; 

Aq. destillat. §ss. Misce. 
Dose, one drop morning and evening for each year of the child's age. 

So small a dose would certainly do no harm, so that the medicine 
might be safely tried. Still, if belladonna is at all a prophylactic, 



200 SCAKLET FEVER. 

it is reasonable to suppose that a larger dose would be more de- 
cidedly so. 

The great importance of the prophylaxis of scarlet fever has 
induced me to state what is known of the effect of belladonna 
employed for this purpose. I am, however, strongly of opinion 
that by far the most reliable prophylactic, of which we have any 
knowledge, is carbolic acid. Our experience in New York city, in 
reference to the employment of this agent as a means of prevention, 
has not been sufficient to enable us to make a positive statement, 
but it has been largely employed by the New York physicians 
under the direction of the Health Board, in the apartments of those 
sick with infectious diseases, and the result, as regards at least 
scarlet fever, has been highly satisfactory. The Health Board 
employ largely carbolic acid, but other disinfectants in addition ta 
it. (Appendix B.) The impure carbolic acid is preferable to the 
purified. Old rags soaked with it may be suspended in the room, 
or it may be sprinkled in the corners of the room, or placed on 
plates two or three times daily with water added. A positive 
statement in regard to the effect in a matter of such importance 
should be based on accurate and sufficient statistics, but it appears 
to me, from cases which I have observed, that the acid thus em- 
ployed not only destroys in great part the infectiousness of scarlet 
fever, but also renders the disease milder in patients who constantly 
inhale its vapor during their sickness. I have been creditably in- 
formed that certain at least of the Sanitary Inspectors of the Health 
Board of New York, whose opportunities for observation are ample, 
entertain similar views. I take pleasure in referring the reader to 
the opinions in reference to the prevention of scarlatina of a British 
practitioner, of candor and great experience, who is favorably 
known to the profession on both continents. For a knowledge of 
the views of this gentleman I am indebted to Dr. Elisha Harris, 
the well-known sanitarian of this city. (Appendix B.) 



STAGE OF INVASION. 201 



CHAPTEB III. 

VARIOLA — VARIOLOID. 

Variola, or smallpox, is a specific febrile affection, accompanied 
by a vesicnlo-pustular eruption of the skin. Since the discovery of 
the protective power of vaccination, it has been shorn of much of 
its terror, but it is still the most loathsome and most dreaded of all 
the fevers. Two forms of this disease are recognized, depending 
on the fact whether there has been previous vaccination. If the 
patient has been vaccinated at some period in his life, the disease, 
which is rendered milder in consequence, is designated varioloid. 
If there has been no vaccination, it is called variola or smallpox. 
Both forms are identical in nature, the one communicating the 
other : they differ only in gravity. 

Smallpox presents four stages: the initial, or that of invasion; 
the eruptive ; that of desiccation ; and, lastly, that of desquamation. 
It is called discrete when the pustules remain separated from each 
other ; confluent when they unite. This division is made accord- 
ing to the character of the eruption upon the face and hands. 
There are parts of the surface, as the abdomen, where the pustules 
are always discrete, even in the confluent form. 

Incubative Period. — During the last half of the last century 
inoculation with variolous matter was extensively practised in 
Great Britain and on the Continent, as it was found that smallpox 
thus communicated was milder than when received by infection. 
This operation enabled physicians to determine the period of incu- 
bation, which was found to be from eight to eleven days. When 
variola is communicated by infection, the incubative period is some- 
what longer, namely, from twelve to fourteen clays. 

Stage of Invasion. — Smallpox begins abruptly with chilliness. 
In children of an advanced age, there is often, as in the adult, a 
distinct chill. This is followed by fever, and such symptoms as 
usually accompany febrile movement, namely, lassitude, anorexia, 
and thirst. There are, in addition, symptoms which, though not 
peculiar to smallpox, are so marked in the commencement of this 
disease, that they possess considerable diagnostic value. These 



202 VARIOLA. 

symptoms pertain to the nervous system. There are in most cases 
of varioloid as well as variola, in the initial stage, severe frontal 
headache, pain in the small of the back, and great drowsiness, 
sometimes with delirium. In many children convulsions occur, 
preceded and followed by a degree of stupor which is almost as 
profound as coma. Trousseau suggests the name rachialgia for the 
pain in the back, as he believes that it is located in or around the 
spinal cord. This belief is based on the fact, which he, as well as 
other observers, has noticed, that there is sometimes in connection 
with this symptom an incomplete paraplegia, indicated by numb- 
ness of the legs, or even inability to use them, and sometimes more 
or less paralysis of the bladder. These paraplegic symptoms pass 
off in a few days. Vomiting is also a common symptom in this stage, 
and one also of diagnostic value. It occurs at short intervals for 
twenty-four to thirty-six hours. The same symptom is common 
in scarlet fever, and not infrequent in measles, but in both these 
affections irritability of stomach is much less persistent than in 
smallpox ; vomiting does not occur in normal rubeolous and scar- 
latinous cases more than once or twice. 

The tongue is covered with a moist fur. If the disease is to be 
discrete, constipation is commonly present in the stage of inva- 
sion; if confluent, diarrhoea is a common symptom, continuing 
till the fourth or fifth day, or even longer. Roseola or erythema 
sometimes occurs in this stage, and this may lead to error of diag- 
nosis, the disease being mistaken for one of these cutaneous affec- 
tions, or even for scarlet fever. The symptoms in the stage of 
invasion are usually more violent in confluent than in discrete 
variola, but there are exceptions. 

Stage of Eruption. — The eruption commences about the third 
day, earlier in some cases, later in others. The average duration, 
therefore, of the first stage is somewhat shorter than in measles, 
but considerably longer than in scarlet fever. Sydenham has 
stated, and observations show the truth of the remark, that the 
shorter the first stage, the more severe the disease will prove to be ; 
and, conversely, the longer the period, the milder will be its form. 
Therefore, if the eruption begins on the second day, it will, as a 
rule, be confluent ; if not till the fifth or sixth day, it will be scanty, 
and the disease light. 

The eruption commences in minute red spots, somewhat like 
those of lichen, which gradually enlarge. It is first observed 
around the lips and upon the neck, then upon the face, scalp, upper 
part of chest, arms, and finally upon the lower part of the chest, the 



STAGE OF ERUPTION. 203 

abdomen, and legs. It is sometimes, especially in young children, 
first observed in the folds of the skin, as about the genitals or in 
the groin. If the cuticle is irritated, as by a sinapism, the erup- 
tion often appears first upon this part of the surface, and in greater 
abundance than elsewhere. The eruption commencing in a minute 
reddish point, as stated above, rapidly enlarges, and soon its cen- 
tral part begins to be indurated and raised. It feels round and 
hard to the finger, is tender, and its diameter does not ordinarily 
exceed two lines. This is the papular stage. The papulse increase, 
and become more elevated, and in twenty-four to forty-eight hours 
from the commencement of the eruptive stage they become vesicu- 
lar. On the fifth day of the eruption, or eighth of the disease, 
the vesicle has attained its fall size. Its diameter is then about 
one-fourth of an inch, and its elevation is two or three lines. Its 
base is circular and indurated, and it is surrounded by a narrow 
zone of inflammation, indicated by redness and tenderness of the 
skin. The pock commonly, as it passes from the papular to the 
vesicular stage, loses its acuminate form, and becomes depressed in 
the centre, but in most cases, mixed with the umbilicated vesicles, 
are some which remain acuminate. 

In proportion as the eruption becomes developed in discrete 
variola, and in varioloid, the symptoms which accompanied the 
stage of invasion abate; the fever, headache, pain in the back, 
and thirst cease, and the appetite returns. In the confluent form, 
the febrile action continues with little abatement. 

Simultaneously with the eruption upon the skin, an eruption 
also occurs upon the buccal and faucial surface, and often upon 
that of the air-passages. It occurs sometimes, also, upon the con- 
junctiva, producing -dangerous ophthalmia, and even ulceration, 
with loss of sight; and upon the mucous surface of the genital 
organs. The form which it presents upon mucous surfaces is some- 
what different from that upon the skin. There is at first a deposit 
of fibrin, producing a small, round, grayish spot at the point of 
eruption — firm, slightly elevated, and covered, if not by the entire 
mucous membrane, at least by its epithelial layer. Ulceration 
soon occurs, as in ulcerous stomatitis, and if the patient live, the 
reparative process succeeds, as in simple ulcers. The eruption upon 
mucous surfaces increases considerably the suffering of the patient, 
in consequence of the tenderness of the ulcers ; and if its seat be 
the surface of the larynx or trachea, it may be the immediate 
cause of death, especially in young children, by obstructing respi- 
ration. 



204: VAEIOLA. 

The cutaneous eruption has been traced to the vesicular stage. 
On or about the fifth day of the eruptive period, or eighth of small- 
pox, the vesicles gradually change their character, their contents 
becoming thicker and turbid. At the same time they increase 
somewhat in size, and the central depression disappears. This is 
designated the stage of maturation, or of suppuration, though it is 
known that the turbidity is due chiefly to another substance than 
pus. The pock having undergone these changes, is termed the 
pustule. 

In discrete variola, and in varioloid, the fever returns during the 
pustular stage; or, if the form of the disease is confluent, and the 
fever has continued, it now becomes more intense. The return of 
fever, or its increase, is denoted by increased frequency of pulse, 
elevation of temperature, dryness of skin, anorexia, and thirst. 
A tendency to constipation remains throughout the disease in vario- 
loid and discrete variola; in the confluent form, diarrhoea more 
frequently occurs, which, if it continue, is an unfavorable prognos- 
tic sign. 

Other changes occur. The pustules increase somewhat in size, 
and become more globular. Some of them, when most distended, 
break through friction of the clothes, or scratching of the child, 
and their contents escaping, add to the loathsomeness of the dis- 
ease. There is in the pustular stage more or less redness of the 
surface between the eruptions, and, except in the mildest cases, 
there is tumefaction from subcutaneous infiltration. In the con- 
fluent form, at this period, the features are often so swollen that 
the friends would not recognize the patient. The eyelids may be 
so oedematous that the eyes are for a time concealed from view. 
This oedema of the surface is not altogether absent in the vesicular 
stage, but it increases during the time of maturation, after which 
it subsides. 

Stage of Desiccation. — This immediately succeeds the full de- 
velopment of the pustules. The liquid portion of the contents of 
the pustules, which are broken, evaporates, leaving a crust. If 
there is no rupture, the liquid is absorbed, and a scab results, which, 
though smaller, preserves in a measure the form of the pustule. 
"While the pustule desiccates, the surrounding inflammation rapidly 
abates. The crusts occur first upon the face, and on other parts in 
the order in which the eruption appeared. The odor from the pa- 
tient, at this time, is peculiar. In the confluent form, especially, 
it is very offensive, and can be noticed at a distance from the bed- 
side. Eilliet and Barthez call it nauseous and fetid. As desicca- 



STAGE OF DESICCATION. 205 

tion progresses, the symptoms, local and general, abate. The pulse 
and temperature, if the case is favorable, return to their normal 
standard. The cough, hoarseness, and thirst disappear, while the 
appetite returns; the sleep is more tranquil, and the functions, 
generally, are more regularly performed. 

The last stage is that of desquamation ; it commences between the 
eleventh and sixteenth days. The scabs, which present a dark or 
brownish appearance, are successively detached. This period lasts 
several days ; sometimes two or three weeks even elapse before all 
the crusts separate. In the meantime the patient gradually re- 
covers his health and former strength. After the fall of the crust, 
the cicatrix underneath presents a reddish appearance. This color 
gradually fades, and there remains an irregular depression, or pit, 
of a lighter color than the surrounding surface; and if there has 
been a full development of the eruption, disfiguring the patient for 
life. 

Such is the clinical history of variola, when it is favorable, and 
its course is regular. The disease is sometimes irregular. In rare 
instances the eruption occurs almost at the commencement of the 
disease. The form is then very apt to be confluent. There are 
irregularities, also, in consequence of diarrhoea, hemorrhages, or 
other complications. I have known the eruption appear first on 
the limbs, and last on the trunk and face, and the appearance of, 
the eruption is not always the same. In the ansemic and feeble 
child it often presents a pale color, with some induration at its 
base, but without the red areola around it, or with this quite in- 
distinct. In rare instances the vesicles have a reddish color, their 
contents being tinged with blood. This form of variola is desig- 
nated hemorrhagic. It indicates a profoundly altered state of the 
blood. The eruption in this form is of small size, and if the pock 
is broken, blood oozes from it. 

Varioloid. — The course of varioloid is similar to that of variola, 
but it is somewhat shorter. It commences with rigors, followed 
by fever, headache, pain in the back, vomiting, drowsiness, and 
sometimes delirium, or even convulsions. The symptoms in the 
stage of invasion are, indeed, the same in character, and often 
nearly as severe as in variola. With the initial symptoms, there 
is also sometimes a scarlatiniform eruption, so that the disease 
may at first be mistaken for scarlatina. On the third or fourth 
day the variolous eruption commences. The number of pocks is 
commonly few, often not more than twelve to twenty. In the 
mildest form of varioloid, if the physician is not summoned in the 



206 VARIOLOID. 

stage of invasion, lie is not apt to be called at all, so that the pa- 
tient may pass through the disease in ignorance of its nature. I 
have known this occur, the true character of the affection not being 
ascertained till others were affected, either with variola or vario- 
loid. 

The eruption pursues a more rapid course in varioloid than in 
the unmodified disease. By the fifth or sixth day the pustules are 
fully developed, though often smaller and less likely to be ruptured 
than in variola. Often, in varioloid, the eruption aborts. It re- 
mains papular two or three days, and then declines, or it may reach 
the vesicular stage, and decline without pustulation. 

The constitutional symptoms in varioloid decline with the com- 
mencement of the eruptive stage. The secondary fever is slight or 
absent. 

Such is the usual mild course of varioloid, but not always. If 
several years have elapsed since the vaccination, its protective 
power is greatly impaired, and varioloid may then exhibit as severe 
a form as ordinary smallpox. In some instances it is fatal. 

The term varioloid is, as has been stated, applied to cases of 
variolous disease where there has been previous vaccination. It 
is also applied by writers to second attacks, whether the first 
occurred from infection or from variolous inoculation, but such 
cases are rare. 

Mode of Death. — Death in smallpox occurs in several different 
ways. The most fatal period is the pustular stage. Feeble chil- 
dren not ^infrequently die from exhaustion at or about the time 
that the pustules attain their greatest size. The eruption appears 
and becomes developed as usual, but there are evidences of weak- 
ness in the patient, and suddenly the progress of the vesicle or pus- 
tule ceases. It begins to subside, and its walls shrivel. There is 
evidently absorption, in part, of the liquid contents. These pheno- 
mena are of the gravest character. Death is the common result, 
and within twenty-four hours. In other cases death occurs from 
apncea. The pock increasing in size in the larynx and trachea, 
obstructs inspiration, or there may be the formation of a pseudo- 
membrane, as in true croup. This is not an unusual mode of death 
in young children, in whom the calibre of the larynx and trachea 
is small. Sometimes convulsions and coma occur in the last hours 
of life. In other cases the stage of desquamation is reached, but 
convalescence does not occur. The patient each day becomes more 
anaemic and feeble, and finally death results from failure of the 
vital powers. Again, after smallpox has run its course, purpura 



ANATOMICAL CHARACTERS. 207 

hemorrhagica may be developed. Hemorrhages occur from the 
gums, throat, nostrils. Blood is vomited, and evacuated in the 
stools. I have known death to occur in all these ways, but that 
from purpura is least frequent. Sometimes, as in scarlet fever, 
death occurs suddenly and unexpectedly in confluent, and even in 
discrete variola, when the previous symptoms had apparently been 
favorable. The patient is overpowered by the intensity of the virus. 
Anatomical Characters. — In those who have died of variola, 
without inflammatory or other complication, the heart-clots have 
been found small, dark, and soft. The blood is dark and thin. 
The vessels of the brain and its membranes are injected, so that 
numerous red points appear on the cut surface of this organ. The 
vessels of the lungs and the abdominal organs are congested, while 
the muscles present a deep red color. The variolous eruption pene- 
trates more deeply than that of any other exanthematic fever. It 
has been stated elsewhere that it occurs not only on the skin, but 
often on the surface of the mouth, fauces, and air-passages. The 
mucous membrane in these situations is frequently also the seat of 
erythematic inflammation, being thickened and softened, and in 
some parts, as the larynx, a pseudo-membrane is occasionally pro- 
duced, as in croup. This inflammation, erythematic or pseudo- 
membranous, may occur without as well as with the presence of 
the specific eruption. 

The eruption very seldom, perhaps never, appears upon the gastro- 
intestinal surface, but the solitary follicles and patches of Peyer 
are often enlarged, as in some other zymotic affections. The liver, 
spleen, and kidneys are commonly congested in those who have died 
of variola. The spleen, especially, is increased in volume and soft- 
ened ; the kidneys are enlarged, as if from commencing nephritis, 
and sometimes softened. 

The minute structure of the pock is described by Rilliet and 
Barthez, and others. The vesicle is multilocular, consisting of 
at least iive or six compartments, with distinct partitions. Its 
centre is united by fibrous bands to the derm beneath , which union 
gives rise to the umbilicated appearance. The giving way of these 
minute bands in the pustular stage occurs when the form changes 
from the umbilicated to the convex. In the pustular stage also, 
according to some, a fibrinous formation occurs within the pustule ; 
according to others, this substance is of the nature of the epidermis, 
presenting the aiopearance of the cuticle when macerated. Mixed 
with this epidermic or fibrinous formation are pus cells. 



208 VARIOLOID. 

Complications. — There are several different complications of va- 
riola. One is salivation. This is common in the adnlt, but rare 
in the child. When it occurs in the child, it is slight, commencing 
with or about the time of the eruption, and disappearing in from 
one to four or five days. Ophthalmia is another complication. Sim- 
ple conjunctivitis, often quite intense, may occur in consequence 
of pustules developed under the lids. This inflammation subsides 
without injury to the eye, as the primary disease abates. A more 
serious inflammation occurs at an advanced stage of the disease, 
commencing in or near the desquamative period. This produces 
more or less chemosis, and sometimes opacity or ulceration of the 
cornea. A similar inflammation may occur in the ear, giving rise 
to otorrhoea, and even in some patients to rupture of the drum of 
the ear. Abscesses in the subcutaneous cellular tissue have been 
occasionally observed, especially in the confluent form. Subcutane- 
ous infiltration and feebleness of constitution favor their occurrence. 
Suppuration within the joints is a somewhat rare complication or 
sequel, rendering convalescence protracted, if, indeed, the case is 
not fatal. 

M. Beraud has published a memoir to show that orchitis com- 
plicates variola in the male, and ovaritis in the female. These 
inflammations are believed to be accompanied by a small and im- 
perfect variolous eruption upon the tunica vaginalis and the peri- 
toneal covering of the ovary. Trousseau states that he has often 
met this complication in the male, since his attention was called to 
it. It is mild, and subsides with the disappearance of the eruption. 
Laryngitis, simple or diphtheritic, bronchitis, pneumonia, pharyn- 
gitis, purpuric hemorrhages, gangrene of the mouth or other parts, 
oedema pulmonum, and oedema glottidis are occasional complica- 
tions, some of which are frequent, others rare. 

Prognosis. — This depends on the age, vigor of system, form of 
the disease, and the presence or absence of complications. The 
younger the child, the greater the danger. Trousseau says : " Con- 
fluent variola, and even discrete variola, are almost always fatal in 
individuals less than two years old." Above the age of three or 
four years discrete variola usually ends favorably, but the confluent 
form is still, as a rule, fatal. Varioloid in the child is a mild 
disease, terminating favorably in a large proportion of cases. It is 
milder at this age than in the adult, on account of the more recent 
period of vaccination, and if a case of supposed varioloid is severe, 
and the eruption abundant, it is probable that the vaccination was 
spurious. 



TREATMENT. 209 

It is not necessary, from what has been said, to specify the 
favorable prognostic signs. The unfavorable prognostics are, great 
violence of the initial symptoms ; early appearance of the eruption ; 
an abundant eruption, especially if pale, and without swelling of 
the surface ; rapid decline of the eruption in the vesicular or pus- 
tular stage ; hemorrhagic eruption, or hemorrhages from the sur- 
faces ; fever continuing after the appearance of the eruption ; 
diarrhoea persisting beyond the third or fourth day ; delirium or 
great drowsiness ; a frequent and feeble pulse ; and, finally, ob- 
structed respiration — if slow, indicating a pseudo-membrane or 
variolous eruption in the larynx or trachea — if rapid, indicating 
bronchitis or pneumonia. 

Diagnosis. — The diagnosis cannot be made with certainty prior 
to the eruptive stage. If, however, smallpox is prevalent, if the 
patient has not been vaccinated, and the symptoms which pertain 
to the period of invasion are present, as headache, pain in small of 
back, repeated vomiting, drowsiness, and perhaps convulsions, there 
is ground for the gravest suspicion. If, in addition to these symp- 
toms, reddish points begin to appear on the second or third clay, 
the diagnosis may be made with confidence. At this early period, 
even before there is any distinct cutaneous eruption, ash-colored 
spots may sometimes be observed on the buccal or faucial surface, 
the commencement of the variolous eruption ; these possess con- 
siderable diagnostic value. 

The scarlatiniform efflorescence, in the first stage of variola, 
sometimes leads to the belief that the disease is scarlet fever. The 
absence of the pharyngitis, and the appearance of the variolous 
eruption soon after the efflorescence, correct the diagnosis. Small- 
pox has, in the beginning of the eruptive period, sometimes been 
mistaken for measles. The points involved in the differential 
diagnosis have been presented in treating of that disease. After 
the development of the eruption it may be mistaken for varicella. 
The eruption of varicella is, however, preceded by symptoms which 
are milder and of shorter duration, and its appearance is different. 
It is irregular, instead of round ; is not umbilicated, and it does not 
have the round, inflamed, and indurated base, which characterizes 
the variolous eruption. The eruption of ecthyma is sometimes 
umbilicated, but the symptoms of ecthyma and variola, and the 
progress of the eruptions in the two diseases, are very different. 

Treatment. — Smallpox, like the other essential fevers, is self- 
limited, and therefore the constitutional treatment should be 
sustaining and palliative. In the first stages of the disease, the 
14 



210 VAEIdLOID. 

diet should be simple ; gentle laxatives and refrigerant drinks are 
required if there is much febrile excitement. Lemonade is a 
grateful drink, and may be given in moderate quantity. Spiritus 
Mindereri or carbonic acid water may be allowed. As the disease 
advances, more nutritious food should be recommended; and in 
severe cases carbonate of ammonia, and even alcoholic stimulants, 
are required. 

As confluent smallpox is nearly always, and the discrete form 
often, fatal in infancy, the physician should carefully watch the 
progress of the case in the infant. By judicious treatment, some, 
in this period of life, may be saved, who otherwise would perish. 
In the infant, depressing measures should be avoided. A laxative 
may be given, at first, if there is much fever, and the bowels are 
constipated ; but the diet should be nutritious, and many soon re- 
quire tonics and stimulants. If the pulse become more frequent and 
feeble, or if, with frequency of the pulse, the face and extremities 
become cool, or if, in the vesicular or pustular stage, the eruption 
suddenly subsides, alcoholic stimulants must be immediately em- 
ployed, or the patient dies. 

Such is an outline of the constitutional treatment required in 
smallpox. Sydenham inculcated a mode of treatment which 
experience has shown to be injurious in infancy and childhood. 
He had observed that the severity of the disease was ordinarily 
proportionate to the amount of eruption, and concluded from this 
fact that measures which retarded the development of the eruption 
were salutary ; cold drinks, a cold apartment, scanty covering of 
the body, cathartics that caused derivation of blood from the sur- 
face, even sometimes the abstraction of blood, were considered, 
according to Sydenham's theory, to be useful as means of preventing 
full development of the eruption. 

Sydenham's treatment, however appropriate it might sometimes 
be in case of robust adults, is unsuitable for children, because they 
do not, as a rule, tolerate, in this disease, measures which reduoe 
the strength. Moreover, smallpox is rendered more dangerous 
by what Eilliet and Barthez designate perturbating treatment — 
treatment which renders it abnormal. The regular appearance 
and development of the eruption are requisite in order that the 
case may progress favorably. On the other hand, the opposite 
plan of treatment, which families, if left to themselves, are apt to 
adopt — namely, the employment of measures to promote perspira- 
tion, as hot drinks, and confinement in a heated room — is also 
injurious. 



TREATMENT. 211 

The patient should be kept in a temperature such as he has been 
accustomed to, and such as is agreeable to him ; his diet should be 
simple and nutritious ; laxative medicine should only be given to 
procure the natural evacuations. In smallpox, as in all infectious 
diseases, free ventilation of the apartment is required. 

While the general eruption in smallpox should not be interfered 
with, it is proper to endeavor to diminish, so far as possible, the 
size of the pocks, on parts exposed to view, so as to prevent dis- 
figurement. Prof. Flint, in his Treatise on the Practice of Medicine, 
has published an excellent summary of the various measures which 
have been recommended for accomplishing this end. First: The 
opening and breaking up of the vesicle by means of a fine needle. 
This is tedious practice in confluent variola, but it can readily be 
performed in the discrete form — at least as regards the vesicles 
upon the face. This treatment was proposed by Rayer, and it is 
recommended by many who have tried it. Secondly : After the evac- 
uation of the liquid, the cauterization of the vesicle by a pointed 
stick of nitrate of silver. Billiet and Barthez say, in reference to 
this mode of treatment, " Individual cauterization of the pustules 
is, on the other hand, an almost infallible means of causing them 
to abort. To be successful, it is necessary to penetrate into the 
interior of the pustule with a pointed crayon of nitrate of silver, 
in order to cauterize the derm. . . . It is only the first or second 
day of the eruption that it (cauterization) has certain success; 
nevertheless, we have often seen it succeed the third or the fourth. 
day, or even the fifth." 

Thirdly: The application of tincture of iodine once or twiee 
daily over the eruption when in the papular stage. Some writers, 
who have employed iodine, state that it does not prevent pitting, 
but diminishes it. Fourthly: The exclusion of light and air by 
means of a plaster. A mixture containing tannate of iron has 
been employed for this purpose in one of our hospitals. This pro- 
duces a black mask. Light and air may also be excluded by 
smearing the face with sweet oil, and dusting twice daily upon the 
oiled surface a powder containing equal parts of subnitrate of bis- 
muth and prepared chalk. Fifthly : The application of mild mer- 
curial ointment upon the face or other parts of the surface, where 
it is desirable to render the eruption abortive. This mode of treat- 
ment does diminish the size of the vesicles and the pitting, but I 
should not recommend it for children. I have known in the adult 
severe mercurialization from its employment for four or five days, 
and, though young children do not exhibit so readily the effects of 



212 VACCINIA. 

mercury, the use of the ointment, unless for a very limited period, 
increases, in my opinion, their feebleness, and diminishes the 
chance of their recovery. Calamine made into a paste with sweet 
oil is said to be equally effectual with mercurial ointment, and it 
produces no constitutional effect. Its effect is obviously similar to 
that of the bismuth and chalk employed with sweet oil as stated 
above. Of late, I have employed pulverized charcoal made into a 
thin paste with sweet oil or glycerine, and applied daily or twice 
daily to the face. It effectually excludes the light, and the result 
has been so good as regards pitting, that I shall continue to use it. 
Poultices, collodion, a solution of gutta percha in chloroform, have 
been recommended, among other substances, by good observers. 
If fissures or excoriations occur, an application may be made of 
oxide or carbonate of zinc in glycerine, one drachm to the ounce. 
The prevention of smallpox, so far as practicable, is one of the 
important incidental duties of the physician. Isolation of the 
patient, and precautions in reference to his clothes and bedding, 
are imperatively required, so great is the infectiousness of this dis- 
ease. The only certain means of prevention is confessedly vacci- 
nation, and providentially the incubative period of the vaccine 
disease is much less than that of variola. Therefore, smallpox, 
may be prevented after the virus is received in the system, by 
timely and successful vaccination. Vaccination, at any period 
between the time of exposure and the commencement of the symp- 
toms of invasion, will either prevent the occurrence of smallpox or 
modify it. If the symptoms of invasion have already commenced, 
jit is uncertain whether it produces any modifying effect. 



CHAPTER IV. 

VACCINIA. 

Vaccinia is a mild eruptive disease, which occasionally occurs 
among cattle, and lias been propagated from them to man. It is 
characterized by the appearance upon the surface of one or more 
papules, which soon become vesicular, and then pustular. It is 
.communicable by contact, but, unlike the other eruptive fevers, it 
is not infectious in man. It is inoculable, both by the liquid con- 



VACCINIA. 2L3 

tained in the vesicle, which is designated vaccine lymph, and by 
the scab which results from the desiccation of the pustule. 

To Gloucestershire, England, the honor belongs of discovering 
and popularizing the fact that vaccinia, a mild and comparatively 
harmless disease, is transmissible from the cow to man, and that it 
affords protection from smallpox. It appears that a vague opinion 
prevailed among the farmers of this dairying section, that a dis- 
ease, which has since been designated vaccinia, was occasionally 
received from the cow in milking, the virus passing from a pustule 
on the teat to a sore or chap on the hand of the milker, and that 
those who thus contract the disease receive immunity from small- 
pox. As usually happens with important discoveries, so dull of 
apprehension is human intellect, these people, to whom Providence 
had revealed so important a fact, were blind to its real value. 
Finally, in the year 1774, Benjamin Jesty, whom the world has 
not sufficiently honored, " an honest and upright man," according 
to his epitaph, a farmer of Gloucestershire, had the courage to 
vaccinate his wife and two children. His excellent moral character 
did not shield him. He was regarded by his neighbors as an inhu- 
man brute, who had performed an experiment on his own family, 
the tendency of which might be to transform them into beasts 
with horns. 

The first essay in vaccination appears to have been entirely suc- 
cessful, but the prejudice against the operation continued. A 
fifth of a century passed, during which there was no extension of 
the benefits of this great discovery. At last, towards the close of 
the last century, Dr. Edward Jenner, a physician of Gloucester- 
shire, and inoculator of his district, began to investigate this 
disease of the cow, about which little was known, and the grounds 
for the belief that it afforded protection from smallpox. Fortu- 
nately for the world, Jenner had been educated under John 
Hunter, and had learned from his great master to study nature 
rather than books, to be guided by experience and observations 
rather than by the dogmas of his predecessors or of the schools. 

Jenner performed his first vaccination on the 14th of May, 1796, 
twenty-two years after Benjamin Jesty had lost his good name 
among his neighbors for vaccinating his own family. The popu- 
larizing of vaccination, mainly through Jenner's perseverance, 
affords one of the most interesting and instructive chapters in 
the history of medical science. How he went up to London, 
full of the importance of the discovery, and was there advised by 
his medical friends to desist from his wild schemes, lest he should 



214 VACCINIA. 

injure the reputation which he had gained by publishing a credit- 
able paper on the cuckoo ; how he was allowed to vaccinate in the 
hospital wards, and gained some adherents to the new faith among 
the leading physicians of the metropolis; and finally, how, as the 
claims of vaccination began to be recognized, at the close of the 
last century and commencement of the present, a most acrimo- 
nious discussion arose, which filled all the medical journals of that 
period. The opponents of vaccination resorted to every device to 
prevent the acceptance of Jenner's views. They attempted to pre- 
judice the people against them by specious arguments, by ridicule, 
and even by pictures. One of the leading journals contained the 
caricature of a cow covered with sores, and devouring children, 
and it was urged that vaccination was a bestial operation, de- 
grading man to the level of the brute. But the truth had gained 
a firm hold, and the practice of vaccination extended. 

The discovery of vaccinia, and of its protective power, cannot 
be too highly appreciated. It has, probably, done more to relieve 
human suffering than any other discovery of the last one hundred 
years, unless we except that of anaesthetics, and more to save human 
life than any other instrumentality of a purely phj^sical kind. 

The fact was established in the time of Jenner that the virus of 
smallpox inoculated in the cow produced vaccinia, which in its 
propagation back to man never returned to its original form, but 
always remained vaccinia. Moreover, Jenner believed that the 
disease known in the horse as the grease was identical in nature 
with vaccinia in the cow. He failed, however, in his experiments 
to communicate vaccinia from the horse, but other experimenters 
have been more successful. In 1801, a Dr. Loy, of the county of 
York, England, met two cases of vaccinia in persons who had taken 
care of a horse affected with the grease, and, from the lymph which 
he obtained, was able to produce vaccinia in the cow. In 1805, 
Viborg, a Danish veterinary surgeon, after many failures, succeeded 
also in communicating vaccinia to the cow by means of the virus 
taken from a horse. 

From this time little light was thrown on this subject till within 
the last twelve years. Although Loy and Viborg, and perhaps a 
few others, had recorded their success, other experimenters had 
failed to communicate vaccinia from the horse. In the absence of 
additional cases, the profession began to question whether there 
might not have been some error in the observations of the gentle- 
men whose names I have mentioned, and the problem was still 



VACCINIA. 215 

regarded as undetermined, whether a disease identical with vac- 
cinia occurred in the horse, or a disease which might communicate 
vaccinia to the cow or to man. 

Observations confirmatory of those of Loy and Viborg were at 
length, however, made, which must be regarded as conclusive. In 
1856, in the department d'Eure-et-Loir, France, M. Pichot was 
consulted by a boy who had on the back of his hands vaccine pus- 
tules, which had apparently reached the eighth or ninth clay. He 
had not taken care of nor been in contact with a cow, but had a 
few days before taken care of a horse affected with the grease. 
Vaccination was performed by means of the lymph taken from 
these pustules, and genuine vaccinia was produced. 

Again, in 1860, an epidemic prevailed among the horses in 
Rieumes and Toulouse, France. A mare sickened with the dis- 
ease, and there was swelling of the hough, with discharge of sa- 
nious matter. M. Delafosse vaccinated two cows with this matter, 
and communicated genuine vaccinia. This epidemic was believed 
by the veterinary surgeons to be an eruptive fever, differing in its 
nature somewhat from the disease or diseases which have ordina- 
rily been designated the grease. It has been conjectured that two 
or more distinct affections of the horse have the same appellation, 
one of which, it is now admitted, is identical with vaccinia of the 
cow, and may communicate it. And the reason why so many ex- 
perimenters have failed to vaccinate the cow from the horse is that 
they have used the virus of the wrong disease, or have taken mat- 
ter from horses which had been affected with the true disease, but 
from ulcers which had lost their specific character. 

Prior to the time of Jenner variolous inoculation was practised 
in most civilized countries, as variola produced in this way was 
found to be milder than when arising from infection. This prac- 
tice is now obsolete ; forbidden in some places by legislative enact- 
ments. It is superseded by vaccination. Vaccination, or the in- 
troduction of vaccine lymph into the system, is quickly and con- 
veniently performed by scarifying with a lancet, and pressing into 
the incisions the lymph, or a little of the scab pulverized, and dis- 
solved in a drop of cold water. It may also be performed by 
scraping off the epidermis with the edge of the instrument till the 
blood begins to ooze ; and also, though with less certainty of suc- 
cess, by puncturing the skin with the point of the lancet, or by an 
instrument called the vaccinator. 

If the child has a vascular neevus, this may be selected as the 
point of vaccination. Unless of large size, it can usually be cured 



216 VACCINIA. 

by the inflammation which vaccinia produces. Statistics collected 
by Simon, as well as Marson, show that of those who contract 
varioloid, the larger the number of vaccine cicatrices the milder 
the disease, and the less the proportionate number of deaths. In 
Simon's statistics of those who stated that they had been vacci- 
nated, but who presented no cicatrix, 21f per cent, died; of those 
who had one cicatrix, 7 J per cent, died ; of those who had two, 4 J 
per cent, died; of those who had three, 1} per cent, died; while 
of those who had four or more cicatrices, only § per cent. died. 
These statistics would seem to indicate the propriety of vaccinating 
in several places. But, so far as appears, when two or more cica- 
trices were observed, the patients may have been vaccinated at 
different times, at intervals, perhaps, of several years, and if so, 
the inference would not follow that more complete protection is 
produced by vaccinating in several places than in one. Moreover, 
if vaccination is performed in the usual manner by several inci- 
sions on the arm, and the virus is fresh and active, usually two or 
more distinct vesicles arise, which unite in their development, and 
probably protect the system as much as if they were separated by 
a wider space. 

Appearances, Symptoms. — In genuine vaccination no effect is 
observed, except the slight inflammation due to the operation, till 
the close of the third day. Then the specific inflammation com- 
mences. This is indicated by a small red point, at first scarcely 
visible, indurated and slightly elevated, as determined by the 
touch, rather than by the eye. This increases, and on the fifth 
day the cuticle over the inflamed part begins to be raised by a 
transparent and thin liquid. The vesicle increases in diameter, 
and by the sixth day presents an umbilicated appearance, and is 
surrounded by a faint and narrow red zone. At the close of the 
eighth clay the vesicle is fully developed. Its size varies consider- 
ably. It is usually from a sixth to a third of an inch in diameter, 
and oval or circular. If the vaccination has been performed by 
incisions, the size of the matured vesicle may be considerably 
larger, and its shape irregular, in consequence of the union of two 
or more vesicles. The eruption now presents a whitish or pearl- 
colored appearance, due to the whiteness of the cuticle, and the 
transparence of the liquid underneath. If the vaccination was 
performed by incisions, it is not unusual to observe over the centre 
of the vesicle, and adhering to it, a small yellowish scab, which 
has resulted from the scarification, and which contains none of the 
virus. 



ANOMALIES, COMPLICATIONS, AND SEQUELS. 217 

The vaccine vesicle, like that of variola, consists of compartments, 
commonly eight or ten, with complete partitions, so that there is no 
intercommunication. On the ninth day the inflamed areola be- 
comes more distinct, and its diameter rapidly increases. Its color 
is deep red, its temperature is considerably elevated, and it is ac- 
companied by more or less induration of the subcutaneous tissue, 
and it is tender to the touch. On the tenth day the pock has 
reached its full development. The areola then extends from one 
to two inches away from the vesicle, becoming fainter at its outer 
circumference, and gradually disappearing in the healthy skin. 
The shape of the outer circumference of the areola is irregular, 
projecting further at one point than another, though its general 
form is circular. 

On the tenth day, when the inflammation has reached its maxi- 
mum, the heat, itching, and tenderness in and around the pock 
are such that the child is often feverish and restless. Occasion- 
ally the glands of the axilla become swollen and tender. In other 
cases, in which there is but a moderate amount of inflammation, 
the constitutional disturbance is slight. 

At the close of the tenth day, or on the eleventh, the inflamma- 
tion begins to decline ; the areola becomes narrower and then dis- 
appears ; the induration and tenderness abate; and with this change 
the pustule desiccates, its liquid is absorbed, and there results a 
brownish or a dark mahogany-colored scab, which is detached, 
ordinarily, between the fourteenth and twenty-first days. The 
cicatrix, at first reddish, like all recent cicatrices, gradually be- 
comes paler, and remains whiter than the surrounding integument. 
It presents several minute depressions or pits, which indicate the 
genuineness of the vaccination. 

Anomalies, Complications, and Sequels. — The vesicle is often 
broken, accidentally, or by the nails of the child. If the top of 
the vesicle is destroyed, or most of the compartments are opened, 
the inflammation is commonly increased, considerable suppuration 
occurs, and there results a large, irregular, yellowish scab, consist- 
ing of the virus mixed with desiccated pus. This scab is entirely 
unreliable, and unfit for the purpose of vaccination, though the 
protective power of the disease is not diminished by injury of the 
vesicles, even if it is totally destroyed. The cicatrix which results 
from extensive injury of the vesicle is apt to be large, and with- 
out the indented points which characterize the normal cicatrix. 

In rare cases, when the inflammation which surrounds the vesi- 
cle is intense and deep-seated, suppuration occurs in the subjacent 



218 VACCINIA. 

cellular tissue, giving rise to an abscess. This abscess is commonly 
of small size, but it increases the fretfulness and constitutional 
disturbance which attend vaccinia. This subcutaneous suppura- 
tion is believed to occur most frequently in those who have a 
scrofulous or vitiated state of system. Inflammation of the lym- 
phatic glands of the axilla I have spoken of as not infrequent in 
vaccinia. This sometimes proceeds to suppuration, producing an 
unpleasant, though not serious, complication. 

It sometimes happens that vesicles appear in other parts besides 
the points where the virus was inserted. These supernumerary 
vesicles commonly occur where the cuticle has been removed by 
scalds or injuries. 

Trousseau relates the case of an infant whom he had vaccinated. 
On the eleventh day he was astonished to find twenty-seven vac- 
cine pustules on the face, trunk, and limbs. This infant had, how- 
ever, before the vaccination, a simple non-specific eruption over 
the whole body, and it was believed that it had produced these 
vaccinations by transferring the lymph, with its nails, to the 
various parts where the cuticle was denuded. 

It is not unusual, also, to observe minute papules appearing on 
paTts of the surface simultaneously with or soon after the vesicle, 
and in a few days declining. These seem to be abortive vaccine 
eruptions. 

One of the most serious complications is erysipelas. This may 
occur directly from the operation, or from the inflammation caused 
by the vesicle, when the virus possesses no deleterious property ; 
and, again, it may result from some unknown element in the virus. 
It may occur immediately after the operation, when it commonly 
prevents the working of the virus, or during the vesicular or pus- 
tular stage ; or, again, after desiccation and separation of the scab. 
I have observed it commencing at all these periods. 

Erysipelas, occurring as a complication of vaccinia, is invaria- 
bly referred by the friends to the virus employed, and the phy- 
sician who has had the misfortune to vaccinate is often unjustly 
blamed. In many of these cases there was a strong predisposition 
to erysipelas at the time of the vaccination, and the operation or 
the inflammation which accompanied the normal development of 
the vesicle served simply as an exciting cause. Erysipelas would 
occur as soon from a non-specific sore ; indeed, we not unfrequently 
are called to cases of this disease in young children, which com- 
menced from non-specific sores upon the genitals, or one of the 
limbs. That the fault is not in the virus employed, is evident 



lNOMALIES, complications, and sequels 



219 



from the fact that other children, vaccinated with, the same, have 
simple uncomplicated vaccinia. 

Sometimes, on the other hand, the cause of erysipelas, whatever 
it may be, exists in the virus. For further facts in reference to 
this subject, the reader is referred to our remarks on erysipelas. 

The fact is established by many observations that syphilis is 
communicable by vaccination. The symptoms of it may not appear 
till vaccinia has terminated, or for a little time subsequently, but 
it then constitutes a very serious sequel. A physician of this city, 
well known in this community as skilful in the diagnosis and 
treatment of skin diseases, and therefore not likely to be mistaken 
as regards the nature of the diseases, states that he communicated 
syphilis to two infants by vaccinating with the same scab. Both 
had the characteristic syphilitic eruption. Recently (January, 
1868) an infant was brought to Prof. Alonzo Clark's clinique, in 
this city, having syphilitic rupia, which, in the opinion of the 
physicians present, was undoubtedly the result of vaccination. 

Trousseau relates the case of a young woman, eighteen years 
old, who was vaccinated with virus taken from an infant appa- 
rently in perfect health. The vaccination was unsuccessful ; but 
twenty-three days subsequently his attention was called to an 
eruption which had appeared in two places on the woman's arm, 
corresponding with the points where the virus had been inserted. 
The eruption was that of ecthyma, which, by the next examina- 
tion, which was five days subsequently, had been transformed into 
rupia. The axillary lymphatic glands were tumefied and indo- 
lent, and, finally, roseola appeared, which removed all doubts as 
to the syphilitic character of the disease. There was syphilitic 
infection, which first manifested itself in the points where vacci- 
nation had been performed (Article de la Vaccine). It is not ascer- 
tained in Prof. Clark's case, nor is it stated in Trousseau's, whether 
the lymph or scab was employed for vaccination ; but it is proba- 
ble that the danger of syphilitic infection is much greater from 
the scab than from the lymph, on account of the amount of animal 
matter which it contains. 

The vesicle in genuine vaccinia is sometimes very small, not 
having a diameter of more than two lines. Occasionally the de- 
velopment of the vesicle is retarded. It does not appear till two 
or three days later than the usual time, or even a longer period. 

Vaccinia is modified by certain diseases. It is arrested by 
measles and scarlet fever, pursuing its course after the subsidence 
of the exanthem. On the other hand, it arrests the paroxysmal 



220 VACCINIA. 

cough of pertussis, which, returns when the pock begins to desic- 
cate. Eczematous eruptions sometimes occur after vaccinia, as 
they often do after the other eruptive fevers ; or, if already pre- 
sent, they may be aggravated. 

Subsequent Vaccinations. 

A second vaccination, performed prior to the ninth day after the 
first vaccination, is successful. A genuine vaccine eruption results, 
which is smaller the more advanced the primary disease. This 
second eruption overtakes the first. On the ninth day the suscep- 
tibility to vaccinia is, in most cases, lost; so that vaccination per- 
formed on the tenth, or subsequent days, is unsuccessful. 

As a rule, a zymotic disease occurs only once in the same indi- 
vidual. Vaccinia is an exception. In most cases, after a few 
years, it can be produced a second time ; and cases of a third or 
fourth successful vaccination, at intervals of a few years, are not 
uncommon. IsTow, subsequent cases of vaccinia differ from the 
first, which has been described above. The period of incubation 
is shorter, and the vesicular, pustular, and desiccative stages suc- 
ceed each other more rapidly, so that the whole period of the disease 
is less. The variation from the appearance and course of the first 
vesicle is jjroportionate to the degree of protection which the first 
vaccination still affords, both as regards smallpox and vaccinia. 
If several years have elapsed since the first vaccination, and the 
protective power which it afforded is nearly lost, the second 
vaccinia differs but little from the first. If, on the other hand, the 
first vaccination still affords nearly complete protection, the result 
of the second is slight; the eruption is insignificant, lacking the 
characteristic appearance of the vaccine vesicle, resembling a com- 
mon sore, and disappearing within a week. It is accompanied by 
no inflamed areola, and by no constitutional disturbance. 

Vaccination often produces no result. This is sometimes due to 
the fact that the lymph or scab employed is useless. It has spoiled 
by keeping, or never has been good. In other cases it is due to a 
lack of susceptibility in the person. Some take vaccinia with diffi- 
culty, and only after several vaccinations ; just as children, though 
fully exposed, often fail to take measles or scarlet fever, on account 
of a condition of the system which prevents the reception of the 
virus, or antagonizes and controls its action. In some instances, 
after vaccination, an eruption is produced, which may or may not 
be genuine; but it immediately becomes purulent, and is soon 



PKOTECTION" FEOM VACCINATION. 221 

broken. A large, yellow, uneven scab results, having none of the 
appearance, and containing little or none of the vaccine virus. This 
scab, as well as the liquid matter which preceded the formation of 
the scab, is utterly useless for the purpose of vaccination, and, if so 
employed, will probably cause a sore from its irritating effect, but 
not of a specific character. If, in place of the true vaccine vesicle, 
the eruption presents the appearance which I have described, 
namely, that of a pustule, soon breaking, and forming a large, 
irregular, yellowish scab, the vaccinia — if it is correct so to desig- 
nate it — must be considered spurious. A sore has been produced 
by the animal matter which was employed in the vaccination along 
with the virus, which has modified the action of the virus, and 
probably has rendered it useless as a means of protection ; or there 
may have been no virus inserted with this animal matter. The 
physician should in such cases insist on a second vaccination. 

Cases like the above are of frequent occurrence, and the parents 
of the child are often satisfied with the result. They see an erup- 
tion following the vaccination, accompanied by considerable inflam- 
mation, and leaving a cicatrix. Unless undeceived by the physi- 
cian, they are apt to remain in the belief of the child's security, 
until, perhaps, it takes smallpox. Such cases, obviously, tend to 
diminish the confidence which the public should have in vaccina- 
tion as a means of protection from smallpox, and on account of 
their frequent occurrence it is important in all cases that the phy- 
sician should see the result of his vaccination. It has been pro- 
posed, as a means of determining the genuineness of the vaccinia, 
to revaccinate when the eruption begins, and if the first is genu- 
ine, the second will overtake it. This is called Brice's test ; but it 
is not necessary, since the physician, familiar with the aj3pearance 
of the true vesicle, can determine at once its genuineness by the 
sight. 

Protection from Vaccnation— Revaccination. 

It was believed by the early advocates of vaccination that the 
general performance of this operation would soon eradicate small- 
pox from the community, so that it would be regarded as a disease 
of the past, rather than of the present time. This result, however, 
is not achieved. As a rule, the greater the benefit of any measure 
designed to ameliorate the condition of mankind, the greater and 
more numerous are the obstacles which diminish its effectiveness. 
Science is full of examples of this. Fortunately these obstacles, 



222 VACCINIA. 

as regards vaccination, are not such as to impair the confidence of 
physicians in its protective power, and it is not too much to expect 
that this simple operation will yet be the means of rendering small- 
pox a disease almost unknown, unless in its modified form. 

Vaccination should be performed in the first year of life. In 
the country, where there is little danger of exposure to smallpox, 
it may be deferred till the age of ten or twelve months. In the 
city, on the other hand, where there is constant intercourse of 
people, and where contagious diseases are often contracted without 
its being known when exposure occurred, an earlier vaccination is 
advisable. Some physicians recommend performance of the opera- 
tion as early as the age of four to six weeks. The objection to 
this is, that if erysipelas occur, so young an infant is apt to perish 
from it, whereas an infant three or four months old ordinarily 
recovers. For this reason I believe that the most suitable age is 
about four months for the city infant, in ordinary times; but if 
smallpox is epidemic, vaccination should Jbe performed at an earlier 
age. I have vaccinated even the new-born infant when smallpox 
had broken out in adjoining apartments. 

Vaccinia usually extinguishes, for a time, the susceptibility to 
smallpox. According to M. G-intrac, varioloid does not occur 
within two years in those who have been vaccinated. It may, 
however, in exceptional instances, occur in a mild form within a few 
months after vaccination. The protection afforded by vaccination 
gradually diminishes by time, but it does not, probably, as a rule, 
cease entirely. Varioloid, however, occurring thirty or forty years 
after a successful vaccination, is apt to be severe, and it may even 
be fatal, showing that it has been but slightly modified. In other 
cases, even after so long an interval, the symptoms present a degree 
of mildness which indicates that the protective power of the vacci- 
nation is not entirely lost. 

If a second vaccination is practised soon after the scab from the 
first vaccination has fallen, it will usually produce no result, but in 
other cases it gives rise to a little redness, swelling, and induration, 
which show that vaccinia has been reproduced, though in a very 
mild and insignificant form. It is probable that in these cases 
varioloid might also occur by exposure, though with a mildness 
corresponding with that of the vaccinia. The longer the period 
after the first vaccination, the greater the number of those in whom 
a second vaccination is effective, and, as has already been intimated, 
the greater also the liability to the variolous disease if a second 
vaccination is not performed. It is recommended, therefore, to 



SELECTION OF VIEUS. 223 

perform a second vaccination not later than the sixth or eighth 
year, and again in childhood. And if smallpox is epidemic, it is 
proper to vaccinate all who have not "been vaccinated within three 
or four years. 

Selection of Virus. 

The lymph is preferable to the scab for vaccination, provided 
that it can be obtained fresh. The scab is more easily preserved, 
and, therefore, if the lymph and scab are old, the latter is to be 
preferred. The lymph should, if the vesicle is sufficiently de- 
veloped, be taken on the fifth day. It may also be taken on the 
sixth, seventh, or even eighth day, provided that the areola has not 
formed. The lymph of the fifth day acts with greater energy, 
though that of the sixth or seventh day is not much inferior. 
Lymph obtained after the formation of the areola is less efficient, 
though it may communicate the genuine disease. 

There is no mode of vaccination so reliable as the use of lymph, 
taken directly from the arm and immediately inserted — the arm to 
arm vaccination. Lymph can be preserved for a few days on a flat- 
tened surface of whalebone, or the segment of a quill ; the former 
I prefer, and if employed within a week, it will usually communi- 
cate vaccinia. Lymph may be preserved a longer period between 
two surfaces of glass, but the best way of preserving it is in capil- 
lary glass tubes. The end of the tube is placed within the vesicle, 
and the lymph ascends by capillary attraction. When a sufficient 
quantity is received, the ends are sealed, by holding them for a 
moment in a flame. Care is requisite in doing this, so as not to 
heat the lymph, as it is spoiled by a temperature much above the 
body. "When the lymph is used, the ends of the tube are broken, 
and by blowing gently through it, a sufficient quantity is received 
on the point of a lancet. 

If the scab is genuine, it presents a dark-brown or mahogany 
color, and has a circular, oval, or at least a rounded form; it is 
firm, or compact, and has a lustre. Soft, yellowish,, and irregular 
scabs are not genuine, and those of a dull appearance, or without 
lustre, have usually spoiled in the keeping. It is the belief of 
many that the vaccine virus gradually becomes weaker by passing 
successively through the human system (Condie, American Journal 
of the Medical Sciences, April, 1865), and that therefore different 
specimens of virus work with different energy, according to the 
degree of removal from the cow. To what extent this view is cor- 
rect is not fully ascertained, but, certainly, if the virus employed 



224 VARICELLA. 

continues to produce a small vesicle, and attended only by little 
inflammation, there is reason to believe that the protection which 
it imparts is less than that from virus which works with greater 
energy, and it should be exchanged for such. The scab is best pre- 
served in soft beeswax, which excludes the air, and it should be 
kept in a cool place. 



CHAPTER V. 

VARICELLA. 



Varicella, chickenpox or swinepox, is the shortest and mildest 
of the eruptive fevers. It is highly infectious, so that few children 
escape who are exposed to it. Its period of incubation is from fif- 
teen to seventeen days. It is not inoculable, or at least those who 
have attempted to inoculate with the lymph of varicella have 
failed. I endeavored to communicate the disease in this way some 
years ago, but without result. It attacks the same individual but 
once, and it occurs as an epidemic. It has been thought by some 
to prevail most immediately before, during, or after epidemics of 
smallpox, and it has been conjectured that it is a modified form of 
variola, and hence its name, which signifies little variola. This 
idea is, however, entertained by few, and it is opposed by the fol- 
lowing facts. Varicella may occur after variola, or variola after 
varicella, without any modification, and the two diseases are very 
dissimilar as regards gravity of symptoms and duration. The va- 
riolous disease, whether smallpox or varioloid, often occurs in the 
adult; varicella, on the other hand, is a disease of infancy and 
childhood. Professor Plint states that he has observed it in the 
adult, but its occurrence at this period of life is rare. Moreover 
varicella and variola have been known to occur simultaneously in 
the same individual. Such a case was reported by M. Delpech, in 
a memoir published in 1845. 

Symptoms. — Varicella usually commences with such symptoms as 
usher in ordinary mild febrile attacks, namely, headache, languor, 
chilliness, and sometimes aching in the back and limbs. Fever 
supervenes, which is usually moderate, the pulse rising perhaps to 
100 or 112, and the thermometer showing an increase of tempera- 
ture, but less than occurs in the other eruptive fevers. These 



DIAGNOSIS. 225 

symptoms, which precede the eruption, are sometimes absent, or 
are so mild as to escape notice. The fever usually ceases on the 
second day, but it may return on the following night. The appe- 
tite is rarely lost, and most children continue, more or less, at their 
amusements. 

The eruption commences in about twenty-four hours, appearing 
as small red points, first over the trunk, and soon afterwards over 
the face and limbs. These points, which are at first minute pap- 
ules, become vesicular in the course of a few hours. The occur- 
rence of the vesicular stage is nearly simultaneous on all parts of 
the surface. The vesicles lack the hard, indurated base of the 
variolous eruption, though they are sometimes surrounded by a 
faint zone of redness. They differ also from the variolous erup- 
tion in the absence of umbilication, and in irregularity of shape. 
Some are small and acuminate, some hemispherical, and of medium 
size, and others oval or elongated, and of large size. The inflam- 
mation is quite superficial, not involving the subcutaneous tissue, 
and scarcely affecting the deepest layer of the skin. 

The vesicles vary in size from the diameter of half a line to 
that of even three lines. They occasionally give rise to slight 
itching. On the second day of the eruption, or third of the dis- 
ease, the vesicles are still fully developed, their liquid contents 
being nearly transparent. At the close of this day the liquid be- 
gins to be somewhat cloudy, and its absorption commences. On 
the fourth day of the disease desiccation progresses rapidly, and by 
the fifth the liquid has for the most part disappeared, and there 
results a scab, small and thin, of a yellowish-brown color. The 
scabs are soon detached, the redness which indicated their seat dis- 
appears, the epiderm which had been raised and removed by the 
eruption is reproduced in its normal state, and in a few days all 
evidence of varicella is effaced. A cicatrix occasionally results, 
but it is due not to the simple varicellar eruption, but to a sore 
produced from the eruption by the scratching of the child. 

The number of vesicles varies considerably in different cases. 
They are never, so far as I have observed, confluent ; but they are 
sometimes so abundant in young children that, if the disease were 
variola, it would be called severe discrete. 

Diagnosis. — Obviously the only diseases with which varicella is 
liable to be confounded are such as present vesicles at some stage 
of their course. From the local vesicular eruptions this disease is 
diagnosticated by the fact that the vesicles appear on all parts of 
the surface. It is sometimes mistaken for variola or varioloid, or 
15 



226 VARICELLA. 

vice versd — a mistake very damaging to the reputation of the phy- 
sician. The points of differential diagnosis are the symptoms of 
invasion — severe, and lasting three or four days in the one ; mild, 
and continuing only one day in the other — an eruption passing 
slowly through its stages from the papulse to the pustulse, umhili- 
cated, with circular, raised, and inflamed base, appearing first on 
the face and neck, and not till a day later on the legs, in the one 
disease ; while in the other the evolution, shape, and course of 
the eruption, as described above, are materially different. By 
proper attention to these distinctive features it is rarely difficult to 
diagnosticate the two diseases. 

The prognosis in varicella is always favorable. It does not, of 
itself, endanger life, nor seriously incommode the patient ; nor does 
it give rise to complications nor sequels. The treatment, there- 
fore, is the simplest possible. Mild diet, and a laxative, may be 
prescribed during the febrile period ; but nothing further is re- 
quired. 



SECTION III. 

NON-ERUPTIVE CONTAGIOUS DISEASES. 



CHAPTEE I. 

DIPHTHERIA. 



The term diphtheria, or diphtheritis, is applied to a blood disease, 
which, like measles or scarlet fever, has a local inflammatory mani- 
festation. The inflammation occurs on mucous surfaces, and the 
skin when denuded of its epidermis, and is attended by fibrinous 
exudation. Diphtheria has of late years attracted much attention 
on the part of physicians as well as the public, on account of its 
epidemic visitation in many different localities, and the great mor- 
tality which has uniformly attended it. It has, of late years, been 
the subject of frequent discussion in the medical societies of Europe 
and this country, and the journals during this period contain nume- 
rous reports of cases, and many monographs designed to elucidate 
its nature. Though there is much that is still obscure in reference 
to diphtheria, the great interest which it has awakened has led to 
a better understanding of its nature, and a more judicious use of 
therapeutic agents. 

' Diphtheria presents itself under two forms, primary and second- 
ary. The primary is more common. The secondary is usually a 
complication or a sequel of scarlet fever or measles, or more rarely 
of typhoid fever, and this form is, therefore, chiefly observed when 
these diseases are epidemic. The two forms are identical in nature, 
symptoms, and appearance ; the difference consisting in the fact 
that diphtheria, when occurring as a complication or sequel, is more 
serious, and apt to be fatal. Ordinarily this secondary form com- 
mences before the primary affection abates, so that there is no inter- 
mission between the two pathological states. The fevers which we 
have mentioned probably predispose to diphtheria, not only from 
the affinity which exists between them and that disease in conse- 



228 DIPHTHERIA. 

quence of their zymotic nature, but from the fact that diphtheria 
is more apt to occur if there is pre-existing faucial inflammation. 
In both measles and scarlet fever the pharyngitis is still present, 
and in many has not begun to decline when the diphtheria com- 
mences. Thus, in a case occurring in my practice, death resulted 
from diphtheria eight days after the commencement of the rubeo- 
lous eruption, the pseudo-membrane being first observed while the 
rash was still present. 

Anatomical Characters. — Before considering the anatomical 
changes which occur in diphtheria, it is well to state what cases 
I consider to be diphtheritic. When this disease is prevailing, 
most observers have remarked the frequent occurrence of pharyn- 
gitis without the pseudo-membrane ; and some hold that these 
cases, as they seem to be due to the epidemic influence, should be 
called diphtheritic. But this would only lead to confusion. We 
might with equal propriety consider the sore-throat, which many 
physicians experience when attending cases of scarlet fever, as that 
disease. The term diphtheria should be limited to those cases in 
which the pharyngitis or other mucous inflammation is attended 
by the formation of patches of pseudo-membrane, for it is only by 
the presence of these that we are enabled to distinguish diphtheria 
from simple inflammation, the constitutional from the local disease. 
By employing the term diphtheria with great latitude, some ob- 
servers have rendered the statistics of this disease, which they 
have published, almost useless. 

The first departure from the state of health doubtless occurs in 
the blood, but the exact changes which this fluid undergoes, as in 
other contagious diseases, have not been fully ascertained. I shall 
hereafter describe the appearance of the blood, as ascertained at the 
autopsies of those who have died of this disease. Immediately 
upon the invasion of diphtheria, redness is observed on some part 
of the faucial mucous membrane, usually that part covering a tonsil 
or in its immediate vicinity. The inflammation thus commencing 
as a faint blush, rapidly extends. The color of the inflamed sur- 
face is sometimes a deep, bright red, almost like arterial blood ; in 
others it is dusky red, which indicates a vitiated state of the blood, 
and is an unfavorable prognostic sign. The dusky-red appearance 
is most common in the secondary form. In a large proportion of 
cases, in the course of a few hours almost the entire faucial surface 
is involved in the inflammatory process. The mucous membrane 
of this part is thickened and softened, its follicles tumefied and 
actively secreting, and there is more or less submucous infiltration. 



ANATOMICAL CHARACTERS. 229 

The intensity as well as the extent of the phlegmasia varies, how- 
ever, considerably in different patients. In a mild attack it is often 
limited to a part of the fauces, and in these cases there are few ex- 
ceptions to the rule that the tonsillar portion is affected, the redness 
gradually fading away in the healthy membrane beyond. There 
is swelling of the tonsils themselves, so that often they nearly touch 
each other. If the pharyngitis is general, the passage through this 
portion of the digestive tube is greatly diminished, but in most 
cases no more, and in many children not so much as in severe 
simple pharyngitis. 

Within a day, and usually within a few hours, from the com- 
mencement of the inflammation, a small semi-transparent and 
almost diffluent point is observed upon the part most inflamed, or 
a thin film, of little importance, did the disease stop here, but very 
significant as a diagnostic sign, and as a forerunner of what is to 
happen. This substance, which is fibrinous, gradually becomes 
firmer, and at the same time thicker and broader, presenting a 
grayish or a grayish-white color. Sometimes different points or 
patches are observed, which extend and coalesce so that the fauces 
are almost entirely concealed from view. The pseudo-membrane 
is closely attached to the mucous surface, which it penetrates, be- 
coming firm, and not easily detached. Attempts to separate it 
often lacerate the engorged capillaries, producing a free flow of 
blood. It does not ordinarily attain a greater thickness than one- 
eighth to one-sixth of an inch. I have seen it, however, not far 
from one-third of an inch thick. 

The same pseudo-membrane is often firmer in one part than 
another, the outer and central portions being more compact and 
tough for a time than that underneath, which is more recent, and 
in which there is less fibrillation. After a few days, however, 
decomposition commences, and then that which was first formed 
becomes softer than the more recent production. When this 
occurs, the color of the exudation changes from a whitish or a 
grayish-white to a dirty brown, and its exposed surface is uneven 
and jagged from the partial separation of shreds and fibres. 

The escape of the liquor sanguinis from the engorged vessels 
diminishes somewhat the turgescence of the inflamed tissue. If 
this is considerable, the pseudo-membrane often sinks below the 
level of the surrounding surface, producing an appearance very 
much like that of an ulcer, or even of gangrene. Though there is no 
loss of substance in this particular state of the surface, it does, how- 
ever, often occur, being produced by the presence and contraction 



230 DIPHTHEKIA. 

of the fibrin with which it is infiltrated. Sometimes the pseudo- 
membrane has a reddish tinge. This is due to rupture of the capil- 
laries, and the escape of the blood corpuscles. It occurs in those 
cases in which the inflammation is intense, and the capillaries are 
greatly engorged. Sometimes the lower part of the exudation is 
blood-strained, while the exposed surface has the usual grayish- 
white hue. (Appendix C.) 

During the height of the inflammation it is astonishing often 
to see with what rapidity the diphtheritic membrane returns, 
when removed by force. A few hours often suffice to restore it as 
firm and extensive as before the interference. If the exudation is 
examined with the microscope as soon as it appears upon the 
faucial surface, it is seen to consist largely of cells, to wit, plastic 
nuclei and pus cells mixed with epithelia ; with these elements, we 
find amorphous matter, and ordinarily delicate interlacing fibrillse. 
Subsequently fibrillation is more complete, and the false membrane 
consequently more firm and resisting* In feeble children fibrilla- 
tion is sometimes lacking, or is so slight as not to be observed with 
the microscope. In these cases the pseudo-membrane is cellular 
and amorphous, and is easily detached. Such was its microscopic 
character in a case which occurred in the Nursery and Child's 
Hospital of this city; the inflammatory product in this patient 
covered the mucous . membrane of the stomach, as well as those 
parts which are commonly the seat of it. This case I shall allude 
to again. 

By the microscope we are able to detect, in some instances, a 
confervoid growth in or upon the pseudo-membrane. This is com- 
monly the oidium albicans, or a plant closely allied to it, or the 
lepothrix buccalis, and its presence has led some observers to think 
that the primary and essential part of the adventitious formation 
is parasitic. Fortunately, so erroneous an idea of the pathology 
of diphtheria is easily disproved, for in most cases of this disease 
no vegetable growth can be detected. The pseudo-membrane does, 
however, constitute a favorable nidus for the growth of confervse, 
like any animal matter of low vitality, or of no vitality, and hence 
the cause of their appearance upon the fauces in this disease. 
Confervse sometimes also grow upon the inflamed surface in simple 
pharyngitis, producing an appearance which simulates closely that 
of the diphtheritic membrane, and it is apt to be mistaken for it 
unless its true character is determined by the microscope. As 
an example of the simple inflammation simulating the pseudo- 
membranous, may be mentioned the case of a little girl in this 



ANATOMICAL CHAKACTEKS. 231 

city, whom I was called to attend when diphtheria was prevailing. 
There was in this patient intense fancial inflammation, with a 
grayish-white substance like fibrin over one tonsil. This sub- 
stance, examined with the microscope, was found to consist of the 
lepothrix buccalis, with epithelia and amorphous matter. The 
disease, which was speedily cured, would without microscopic 
examination have passed for diphtheria. 

In favorable cases the false membrane is detached in a few days, 
and is either expectorated or swallowed with the ingesta. Its 
separation is promoted by the secretions underneath, especially 
by pus, which is formed in abundance between it and the surface 
on which it lies and which it penetrates. In many, perhaps a 
majority of cases, however, it does not separate in mass, but by 
progressive liquefaction. A little less of the pseudo-membrane is 
observed at each visit, until it entirely disappears. Such are the 
appearance, character, and history of the pseudo-membrane in this 
disease. Its common seat is upon the fauces, and in mild cases 
it is ordinarily found there alone. Unfortunately, the nature of 
diphtheria as a blood disease renders all the mucous surfaces liable 
to be attacked by the inflammation, and therefore in severe cases, 
and even in cases of moderate severity, we often find this product 
elsewhere, as well as upon the fauces, and in localities where, from 
its mechanical effect, it greatly increases the danger, and even 
compromises life. The mucous membrane of the nostrils, mouth, 
larynx, trachea, oesophagus, stomach, conjunctiva, vagina, and even 
the delicate lining of the external ear, are at times the seat of 
diphtheritic inflammation, with the characteristic product. If the 
exudation occur in the larynx, or air-passages below the larynx, 
we have the phenomena and result of true croup ; if upon a surface 
concerned in the digestive process, this function is more or less 
interfered with. I have already alluded to a case which occurred 
in the Nursery and Child's Hospital of this city, in which patient 
the surface of the stomach was almost completely lined with the 
diphtheritic formation, so that the function of this organ was appa- 
rently nearly or quite abolished. The occurrence of the pseudo- 
membrane in the nares is common, and is attended by the discharge 
of thin mucus and pus ; but though inconvenient to the patient, 
its presence in this situation is not dangerous, except in the nursing 
infant, in whom it interferes more or less with lactation. The thin 
irritating discharge produces excoriation around the nostrils and 
upon the upper lip. 

Diphtheria is ordinarily attended by inflammation of the cervical 



232 DIPHTHERIA. 

glands, which lie in the connective tissue behind and below the 
angle of the lower jaw, and in cases of great severity this tissue is 
also involved, becoming swollen and indurated. The adenitis begins 
early, and corresponds in degree with the pharyngeal inflammation. 
It is never or very seldom as great in simple pharyngitis as in this 
disease. Great external swelling of the neck, indicating a grave 
form of diphtheria, is, therefore, to be regarded as an unfavorable 
sign. The inflamed glands and connective tissue are hard and tender 
on pressure, but they less frequently suppurate than when similarly 
affected in scarlet fever. I have known but two instances of sup- 
puration, the pus in both escaping externally through the skin. 

The exudation occurs also on the cutaneous surface when blis- 
tered or abraded, and upon the edges of the wound produced by 
tracheotomy. This fact is interesting, as showing the pervading 
character of the diphtheritic virus. 

Bronchitis is often present in diphtheria, with or without fibri- 
nous exudation in the tube. Pneumonia is also so often present, 
that its occurrence is something more than mere coincidence. 

In those who have died of diphtheria the blood has been found 
of a dark-red color, sometimes almost brown. Its appearance has 
been compared, on account of its color, to prune-juice. This color 
is due, partly, in those who have died from apncea in consequence 
of exudation in the larynx, to imperfect oxygenation of the blood, 
but it is also due to the malignant nature of the disease, as in the 
worst forms of scarlet and typhus fevers. The heart-clots are dark 
and soft. 

Apart from inflammation of the tonsils and cervical glands, the 
glandular organs are not changed in their anatomical character, so 
far as ascertained, with the exception of the kidneys. The state 
of the kidneys, and character of the urine, will be described here- 
after. 

Symptoms. — As with other contagious diseases, the symptoms 
vary greatly in intensity in different cases. In general, in the com- 
mencement of an epidemic, diphtheria is more severe and fatal, and 
its symptoms more violent, than when the epidemic influence is 
abating. The prominent symptoms are, however, often dispropor- 
tionate to the gravity of the attack. Striking examples of this 
fact might be given from cases in my practice, the friends not sup- 
posing that there was any serious ailment, and not seeking medical 
advice till the fatal termination had nearly arrived. Diphtheria 
corresponds, in this respect, with all those affections in which the 
blood is profoundly altered. 



SYMPTOMS. 233 

The invasion of this disease may he gradual. There is a degree 
of chilliness, with rigors, often slight, succeeded by more or less 
fever, headache, languor, and loss of appetite. Still, the patient, if 
old enough, continues to walk about as if affected with a slight and 
temporary ailment. The symptoms are like those of a cold, for 
which, indeed, the initial stage of diphtheria is often mistaken. 
"With many, one of the first symptoms is slight tenderness or a 
sensation of fulness in the fauces. A distinguished clergyman of 
the Pacific coast, who fell a victim to this disease, dreamed a few 
nights before he complained of illness that his throat was cut. 
Doubtless the diphtheritic inflammation had already commenced, 
so that what seemed a forewarning had a natural explanation. So 
insidious was the commencement in this case, that the disease had 
advanced beyond all hope of relief when medical advice was first 
sought. 

In other cases the invasion is more abrupt and severe. Great 
febrile reaction, headache, pain in the ear, aching of the limbs, and 
loss of strength, compel the patient to take to bed from the first. 
Delirium may be present, but it is unusual. 

The symptoms of invasion have but little prognostic value. I 
have met cases with a severe commencement, attended by delirium, 
which terminated in complete restoration to health in less than a 
week, the presence of the membrane upon the fauces, and the occur- 
rence of diphtheria in other members of the family, rendering the 
diagnosis certain. On the other hand, the milder commencement 
frequently ushers in a fatal form of the disease. 

The slight soreness of the throat or sensation of fulness, which 
accompanies the initial stage of diphtheria, does not ordinarily 
become any more severe during the course of the attack, and it 
often disappears within a few days. The pain on swallowing, and 
the tenderness when pressure is made upon the throat, are usually 
less than in quinsy or simple pharyngitis. The absence or mild- 
ness of local symptoms is the main reason why the disease is so 
often overlooked in its first stages. I have known more than once, 
in consequence of the slight tenderness in the throat, the large ex- 
ternal swelling to be mistaken for that of mumps, till an incurable 
stage of the affection was reached. I was once asked to see a little 
girl about ten years old, on account of this external swelling, which 
was limited to one side, and the character of which the parents did 
not understand. A physician visiting near by a few days pre- 
viously, had been asked to see this patient, and, without examining 
the fauces, attributed the swelling to inflammation of the root of 



234 DIPHTHEEIA. 

t 

a tooth, and had not thought it necessary to repeat his visit. This 
child, now within three or four days of her death, was walking 
about, not complaining of her throat, but with poor appetite, and 
' with the pale, cachectic aspect so common in advanced diphtheria, 
and having severe inflammation of the fauces, with a thick and firm 
pseudo-membrane extending from the pharynx forward to the arch 
of the mouth. The mildness of subjective symptoms was strikingly 
shown in another case which came to my notice. A little girl had 
been ailing a few days, and had the external cervical swelling, but 
continued about the house and amused herself with playthings, 
even jumping the rope a few times on the day of her death. Finally, 
she sank- rapidly of exhaustion, dying before a physician could 
arrive. These sudden and unexpected deaths in diphtheria are 
due to the profoundly altered state of the blood. If the inflamma- 
tion invade the larynx, then the symptoms are immediately con- 
spicuous and alarming. 

The tongue in diphtheria is covered with a moist fur ; sometimes 
more or less of the exudation appears upon it ; the appetite is poor ; 
bowels regular. The pulse in different cases varies greatly in vol- 
ume and frequency. It is often full and strong in the first days of 
the disease, but in the latter part, when death from asthenia ap- 
proaches, it is feeble and frequent. At first there are no marked 
symptoms referable to the respiratory apparatus. There is only that 
degree of acceleration of respiration which corresponds with the 
amount of fever. In many cases, favorable as well as unfavorable, 
there is no cough and no embarrassment of respiration throughout 
the entire sickness, though the inflammation of the faucial surface 
may be general and severe, and the constitutional disturbance very 
decided. But ordinarily, in the course of a few days from the 
inception of the disease, the swelling of the nasal mucous mem- 
brane, and the occurrence of exudation upon it, produce snuffling 
respiration. The occurrence of the phlegmasia upon the laryngo- 
tracheal surface is indicated by hoarseness of the voice, and an occa- 
sional dry cough, and as the inflammation extends and the pseudo- 
membrane forms, the cough becomes more frequent, and harsh or 
raucous, as in true croup. Indeed, the condition of the patient, 
as regards the larynx and trachea in diphtheria, when they are the 
seat of fibrinous exudation, resembles that in true croup. As the 
inflammation in the larynx and trachea, when accompanied by 
fibrinous exudation, is rarely amenable to treatment, the symptoms 
of obstructed respiration become more continuous and severe as the 
disease advances, till finally the dyspnoea is extreme ; the inspira- 



SYMPTOMS. 235 

tion is protracted and whistling, and accompanied by great depres- 
sion of the ribs; the countenance is anxious and pallid; the prola- 
bia and fingers livid, and the little patient in vain seeks for relief 
by change of position. Occasionally, by great effort on the part 
of the child, or by fortunate treatment, a portion of the pseudo- 
membrane is expectorated, and for some hours there is apparently 
marked improvement, but it is only in exceptional cases that the 
membranous formation is not speedily and fully reproduced. As 
death draws near, the cough diminishes both in frequency and force. 

In cases of a severe type the breath is ordinarily offensive, having 
a gangrenous odor. There is in such patients intense pharyngitis, 
with a pseudo-membrane which, from its low vitality, rapidly un- 
dergoes decay, and also great external swelling from the adenitis 
and cellulitis. 

An efiiorescence is sometimes observed upon the surface during 
the period when the temperature of the skin is exalted. This rash 
does not differ from ordinary erythema so common in the febrile 
and inflammatory affections of infancy and early childhood. It is 
not attended by the minute papulse which produce roughness of 
the surface in scarlet fever. It is the erythema fugax of dermatolo- 
gists suddenly appearing, and after some hours as suddenly disap- 
pearing. In many patients it is absent, and it is seldom if ever 
observed, except in the first days, when there is an active circula- 
tion. 

The symptoms pertaining to the nervous system, which are ordi- 
narily most prominent, I have already described. I have described 
the cephalalgia and muscular pains, which are present in the initial 
period, but they soon abate. Convulsions may occur in young 
children, but not oftener than in other diseases attended by febrile 
reaction. 

The heat of surface is in most cases less than in scarlet fever ; it 
abates in a few days, and in advanced stages of the disease the 
temperature is natural or less than natural. The abdominal organs 
are seldom much affected in diphtheria, so far as ascertained, with 
the exception of the kidneys. There have not been many chemical 
examinations of the urine in this disease, but in a few which have 
been made (Sanderson, British and Foreign Medico-Chir. Hev., Jan- 
uary, 1860), the quantity of urea excreted daily was found to be 
considerably more than when convalescence had commenced. The 
most interesting and important change, however, in the constitution 
of the urine, is the occurrence of albumen in it. This element was 
first discovered by Mr. Wade, of Birmingham, in 1857, and since 



236 DIPHTHERIA. 

then various observations in different epidemics and localities 
establish the fact that albuminuria occurs in the majority of cases 
of severe diphtheria, and in many of a mild form. It often occurs 
at an early period, but in other patients it does not appear till the 
close of the first week, or commencement of the second. It con- 
tinues three or four days to as many weeks, when in favorable cases 
it gradually becomes less and soon disappears. While albuminuria 
is more common in diphtheria than in scarlet fever, the quantity 
of albumen in the urine is ordinarily less than in that disease. The 
albuminuria of diphtheria is further distinguished from that of 
scarlet fever in the fact already stated, that it ordinarily occurs in 
the midst of the disease, and is attended by slight anasarca, often 
by none, whereas in scarlet fever it occurs after the subsidence of 
the fever, is attended by greater anasarca, and even serous effusion 
in the cavities. If we examine the albuminous urine of diphtheria 
with the microscope, we find in it fibrinous casts and altered renal 
epithelial cells. These cells are opaque or granular, mainly from 
the deposit of fatty particles in their interior. But this appearance 
of the cells is not peculiar to diphtheritic albuminuria. 

Albuminuria in diphtheritic patients is, in the present state of 
our knowledge, rather a matter of scientific interest than of prac- 
tical importance. It does not seem to be an unfavorable prognostic 
sign, and in most cases it requires no special treatment. Occasion- 
ally there is a considerable amount of albumen in the urine in 
cases which are not severe, and the quantity in. the same patient 
may vary from day to day. In some grave cases of diphtheria the 
urine is scanty, and there is then danger of ursemic poisoning. If 
there is great and continued deficiency, death may occur from this 
cause in convulsions and coma. 

The course of diphtheria, like the intensity of its symptoms 
varies greatly in different cases, whether the result be favorable or 
unfavorable. Complete recovery may occur within a few days, less 
indeed than a week, but in other and perhaps a majority of favora- 
ble cases weeks elapse before the health is completely restored. 
When the disease is so protracted, the pseudo-membrane is detached 
slowly, or being detached, it is reproduced again and again. In 
these lingering cases, the countenance bears the appearance of 
marked cachexia, the appetite remains poor or capricious, the 
features are pallid, the body more or less wasted, and the strength 
reduced. Convalescence of such patients is slow and protracted, 
even after the inflammation has entirely disappeared. 

The course of diphtheria lacks uniformity in fatal not less than in 



NATURE. 237 

favorable cases. 1 1 have known death to occur in a robust child of 
two years and three months on the fourth day, without cough, and 
entirely from the malignant nature of the affection. The strength 
was overpowered, and life so suddenly extinguished by the intensity 
of the diphtheritic virus. In this case there was great external 
swelling and intense pharyngitis. In other cases, as has been pre- 
viously stated, death occurs from diphtheritic croup. In other, and 
a large proportion of fatal cases, the disease is more protracted. 
Without embarrassment of respiration, and often apparently with 
but moderate inflammation, the patient gradually loses flesh and 
strength. The face presents a pallid and cachectic aspect, and 
sometimes there is a general flabby or cedematous appearance; the 
appetite is poor, and is improved but little by tonics ; the pulse 
is accelerated, and is day by day more feeble, till, finally, death 
occurs from asthenia. In these lingering and dubious cases, all 
hope of recovery is sometimes dissipated by the occurrence of 
abundant hemorrhage from the throat, in consequence of detach- 
ment of the pseudo-membrane and consequent rupture of the 
capillaries, or possibly sometimes from ulcers in the throat. I was 
once treating a little girl about nine years old with diphtheria 
accompanied by pretty severe pharyngitis, and she had entered 
the third week, with prospect of a favorable issue of the disease, 
when she was suddenly seized with profuse hemorrhage from the 
fauces, which was repeated, and death occurred in forty-eight hours. 
So unexpected a result was apparently due to separation of the 
false membrane. 

Nature. — Though the inflammatory lesions in diphtheria are 
so severe and dangerous, they sustain a secondary relation to the 
disease itself. Diphtheria must be placed in the same category 
with smallpox, scarlet fever, measles, and other infectious diseases. 
Like them, it is due to a specific virus. These diseases, though 
dissimilar in nature and appearance, are controlled by the same 
general laws, so that they are very similar as regards the mode of 
their occurrence. That there is a miasm generated in the persons 
of those affected, and which propagates the disease, is shown by 
numerous observations. The infectious nature of diphtheria is, 
however, doubted by some, though admitted by most pathologists. 
Facts such as those which prove the communicability of scarlet 
fever and measles, have been repeatedly observed in reference to 
diphtheria. Diphtheria, if it enters a family of children during 
its epidemic prevalence, usually attacks more than one. It attacks 
those who remain in the same room with a diphtheritic patient, 



238 DIPHTHERIA. 

while those staying in separate apartments escape. In the late 
epidemic of diphtheria in this city, I was asked to see a boy about 
ten years old with diphtheria. The father had left home a few 
days previously, and escaped the disease. A servant girl, who was 
much frightened and remained in a distant part of the house, also 
escaped. Three sisters, who were daily exposed to the boy, took 
the disease within the ensuing week, in a mild form. All had the 
pseudo-membrane, though of limited extent. Such facts, and 
there are many of a similar nature contained in the literature of 
diphtheria, establish the doctrine of the communicability of this 
disease as securely as almost any doctrine in pathology. 

It is not known certainly whether diphtheria is inoculable, but 
it is believed by many that the saliva and pseudo-membrane of a 
diphtheritic patient, applied to the abraded cutaneous surface or to 
the mucous membrane, may communicate the disease. The illus- 
trious Valleix, whose writings hold so conspicuous a place in the 
literature of children's diseases, was attending a child with diph- 
theria. One day, on examining the throat of his patient, he re- 
ceived in his mouth a little of the saliva, ejected in the effort of 
coughing. The next day a small concretion appeared on one tonsil. 
The inflammation and the pseudo-membrane extended, and in 
forty-eight hours Valleix died, though his patient recovered. This 
case and others similar to it, which have been published, do not 
prove the inoculability of diphtheria, for the same result might 
have occurred in the ordinary mode in which contagious diseases 
are transmitted, namely, by infection. But as all who have seen 
much of diphtheria, from the time of Bretonneau, have now and 
then observed cases analogous to that of Valleix, it is the part of 
prudence, till the question of inoculability is settled, to avoid all 
needless exposure. Bretonneau believed not only in the inocula- 
bility, but that this was the only way in which diphtheria is com- 
municated. 

Diphtheria also, like typhus fever, often occurs without exposure. 
Whenever it visits a region, it commences in localities remote from 
each other, some of which are so secluded as to negative the idea 
of importation. For example, in this country as well as in Great 
Britain, during the recent epidemic, it prevailed in remote farming 
sections as early and sometimes earlier than in the commercial 
centres. Children who had lived for months secluded in farm- 
houses were sometimes the first to be affected. 

Infectious diseases have a period of incubation. Observations 
show that this is short in diphtheria, though, as in scarlet fever, it 



SEQUELS. 239 

seems to vary in different cases. This period is^usually from two 
to seven days. 

Diphtheria, whatever the local manifestations, is always essen- 
tially the same disease. A mild may communicate a severe form, 
and vice versa, and cases, which at first view might appear to he 
different on account of difference in the seat of the phlegmasia, are 
shown to be identical in nature by occurring together, and in conse- 
quence of the same exposure. 

Allusions have already been made to the epidemic character of 
•diphtheria. Sporadic cases occasionally occur. The epidemic form 
is more severe and fatal than the sporadic. The history of the 
various epidemics shows the universality of the specific virus, for 
diphtheria has prevailed in all seasons, in all or nearly all climates, 
in the rural districts, remote and sparsely settled, as well as in 
cities, and in mountainous regions as well as in valleys. It is, 
however, most prevalent and fatal where anti-hygienic conditions 
prevail, as in the tenement-houses of the city, and especially in such 
apartments as are dark and damp, but which necessity compels the 
poor to occupy. A large proportion of the severe cases seen by 
myself, during the recent epidemic in New York, occurred in the 
upper part of the city, along the old watercourses, where, in conse- 
quence of grading of the streets, there was more or less stagnant 
water, which was impregnated with decaying animal and vegetable 
matter. In these localities, even where the population was sparse, 
some of the first as well as last cases of the epidemic occurred, and 
a large portion of those affected died. 

Diphtheria occurs at any age. I have known the infant of three 
months die of it, and many adults fall victims when it prevails as 
an epidemic. Much the largest number of cases, however, occur 
between the ages of two years and eight or ten. The occurrence 
of this disease at so early an age as three months, and, on the other 
hand, in adult life, affords one point of contrast between diphtheria 
and scarlet fever, as well as true croup, both which rarely occur at 
so early and so advanced an age. 

Sequels. — Those who recover from a severe attack of diphtheria, 
remain often for weeks with a pale and cachectic appearance. The 
blood is evidently profoundly altered, so that there is a deficiency 
of red corpuscles or a state of spangeinia, which slowly disappears. 
This is a common result of protracted constitutional diseases, but 
it is more noticeable after this than most kindred affections. The 
excretion of albumen from the kidneys no doubt increases mate- 
rially the impoverishment of the blood. 



240 DIPHTHERIA. 

There is another sequel, which possesses great interest, as it is 
common in diphtheria, and as its etiology is not fully understood. 
This sequel is paralysis. Paralysis does not occur till after the 
abatement of the inflammatory symptoms. The patient seems fully 
convalescent. The fever has ceased ; the appetite is returning ; the 
anaemia is becoming less, and there is prospect of speedy restoration 
to health, when this nervous affection is developed. The interval 
between the subsidence of the inflammation and the commencement 
of the paralysis is usually two or three weeks. The muscles most 
frequently affected are those of the pharynx, so that deglutition is 
rendered difficult, to such a degree often, that nutrition is seriously 
interfered with. The aliment taken passes back through the nos- 
trils, or is not swallowed till after several successive efforts. In 
the attempt to swallow, a portion of the food sometimes enters the 
larynx, so as to produce violent coughing. As we observe the dys- 
phagia, it seems as if there must be pharyngitis, which renders 
deglutition difficult, but on inspecting the fauces we find no evi- 
dences of inflammation. The mucous membrane has recovered its 
normal appearance, and the nerves only are affected. The velum 
palati hangs flaccid and motionless, like a curtain. In some there 
is only pharyngeal paralysis, but in many this nervous affection 
occurs in other parts. Whenever it occurs elsewhere, the pharyngeal 
muscles are nearly always involved at the same time. Diphtheritic 
paralysis may affect the motor muscles of the eye, causing strabis- 
mus; the muscles of one side, causing hemiplegia; of the legs, caus- 
ing paraplegia ; or of an arm on one side and leg on the opposite. 
It does not commence simultaneously in the various muscles which 
are affected, but in succession, those first affected being for the most 
part the muscles of the pharynx. In some the muscles of the blad- 
der have been paralyzed, leading to retention of urine or difficulty 
in passing it. Paralysis in the limbs is frequently preceded by 
tingling or a sensation of formication. There is often not a total 
loss of sensation or of motion in the paralyzed part, but there is 
numbness with great difficulty rather than impossibility of motion. 
A few cases have been reported in which the paralysis was almost 
general, and some believe that they have met cases in which the 
heart was paralyzed, death occurring suddenly and unexpectedly. 
Dr. J. B. Reynolds relates a case in the New York Journ. of Med., 
May, 1860, in which there was not only strabismus, partial paralysis 
of the limbs, and paralysis of the muscles of the pharynx, so that 
food was regurgitated, but the head dropped forward so that the 
chin rested on the sternum. 



PROGNOSIS. 241 

A majority of those affected with paralysis recover, although few 
regain the complete use of their muscles in less than one month, 
and many do not till between two and four months. 

Defect of vision is an occasional result of diphtheria ; some have 
presbyopia ; others myopia ; some see double ; some are amaurotic ; 
while in others one pupil is more dilated than the other, or both 
pupils are dilated, and feebly sensitive to light. This impairment 
or perversion of vision gradually disappears as the vigor of system 
returns. 

Prognosis. — The prognosis in diphtheria is more favorable when 
it occurs sporadically, or at the close of an epidemic, than when the 
epidemic influence is prevailing. Though a constitutional disease, 
its gravity is in a majority of cases proportionate to the local symp- 
toms. Therefore, intense pharyngitis, an extensive pseudo-mem- 
brane, and great cervical cellulitis and adenitis, indicate a form of 
the disease which usually proves fatal in the robust as well as 
weakly. When the inflammation extends to the larynx, and the 
phenomena of croup arise, there is slight prospect of recovery. 
Pseudo-membranous laryngitis is then present in addition to the 
depressing influence of the diphtheritic virus. The local disease, 
apart from the constitutional, we know to be ordinarily fatal. 
Much more unfavorable, then, is the prognosis if the two are com- 
bined. When the croupy cough, voice, and respiration are observed, 
he will seldom err who predicts a fatal result within a week, and 
often death follows in two or three days. 

Great acceleration of the pulse continuing after the first week, 
a countenance pallid, with softness or flabbiness of the tissues, the 
occurrence of hemorrhage from the fauces or other parts, are prog- 
nostic of an unfavorable ending. The secondary form of diphtheria 
is more apt to prove fatal than the primary, in consequence of the 
depressing effect of the antecedent disease. 

From what has already been stated, it is obviously injudicious 
to predict a favorable or an unfavorable termination from the cha- 
racter of the initial symptoms, since an obstinate and fatal case 
often commences mildly, and cases easily managed may commence 
with violent symptoms. But if the inflammations, mucous and 
glandular, remain of a mild grade, if the pulse is not greatly accele- 
rated, if the constitution is good, and there are no laryngeal symp- 
toms, a good result is highly probable. 

In many cases, after the active symptoms have somewhat abated, 
the result for days or even weeks is uncertain on account of the 
anaemia, A majority, however, who have passed through diph- 
16 



242 DIPHTHERIA. 

theria, recover, even if there is great impoverishment of the blood, 
provided that there are no serious local symptoms. Diphtheritic 
paralysis, which is so alarming to friends, may continue several 
months, but it is very seldom permanent, perhaps never. Only in 
exceptional instances do patients affected with it die. This result 
is probably due in general to imperfect nutrition, resulting directly 
from the diphtheria, or from the dysphagia, which is present in 
consequence of the paralysis. 

Diagnosis. — The liability of mistaking simple pharyngitis, when 
attended by the growth of confervse, for diphtheria, has been already 
sufficiently pointed out. By the microscope the diagnosis in such 
cases is rendered easy. The greater amount of external swelling in 
pseudo-membranous pharyngitis is also a means of distinguishing 
this disease from the simple form. There is, in some cases, a close 
resemblance of diphtheria to scarlet fever, especially as regards 
the condition of the system generally, the pharyngitis, and the 
external glandular swelling. The rash upon the skin, and the ab- 
sence of a pseudo-membrane upon the fauces, in scarlet fever, are 
usually sufficient to establish the diagnosis. In almost all cases of 
diphtheria, this pseudo-membrane can be seen on inspecting the 
fauces. The cases in which it is not visible, during the active 
period of the disease, are so few that no account need be taken of 
them. The superficial gangrenous state of the throat, occasionally 
present in scarlet fever, can be distinguished by careful examination 
from the pseudo-membranous pharyngitis of diphtheria. Occasion- 
ally anginose scarlet fever is attended by a fibrinous exudation, 
especially upon the tonsils, but the quantity is small, unless, in- 
deed, there is at the same time diphtheria. Practically, however, 
it matters little whether we make a differential diagnosis of scarlet 
fever and diphtheria, as the two require very similar therapeutic 
measures. 

Diphtheria, with the pseudo-membranous laryngitis, and true 
croup, present great similarity as regards symptoms. One has often 
been mistaken for the other, to the detriment of the patient, for 
these two diseases require different treatment. With proper care, 
however, in examination, with a knowledge of the history of the 
case, the character of the affection can generally be ascertained. 
The inflammation of croup generally begins in the larynx, and the 
pharynx, though inflamed, is inflamed secondarily; whereas the 
inflammation of diphtheria begins in the pharynx, the laryngitis 
occurring some days later. Therefore, in diphtheria there is usually 
the fever, with tenderness and tumefaction of the faucial surface, 



TREATMENT. 243 

and fibrinous exudation, before the cough or other symptoms of 
laryngitis occur. In croup the characteristic voice and cough are 
present from the first, and if we inspect the fauces in the com- 
mencement of the disease, we find only a degree of redness, and 
though at a later period points or patches of pseudo-membrane 
may be observed, the inflammation of the pharynx remains less 
intense throughout the disease than that of the larynx, as shown 
by the symptoms. The pseudo-membrane of diphtheria penetrates 
the mucous coat, and is fibrinous; while that of croup lies on the 
surface, and consists chiefly, if not entirely, of degenerated epi- 
thelial cells, with mucus and pus. By attending to these par- 
ticulars, a correct diagnosis of croup and diphtheria can ordinarily 
be made. 

Treatment. — It has been proposed, in the treatment of this and 
other infectious diseases, to give medicines to prevent the supposed 
fermentative processes going on in the economy, and by this means 
to ameliorate, if not entirely control, the morbid action. Prof. 
Polli, of Milan, has recommended for this purpose the use of the 
sulphites, in the belief that the sulphurous acid set free in the sys- 
tem by their decomposition, prevents, or tends to prevent, catalysis. 
Experiments have shown that this agent does check fermentation 
without the system, and the theory of Polli possesses a degree of 
plausibility. But in such matters the only reliable guide is expe- 
rience. The doctrine of catalysis in disease is indeed merely, as 
yet, an hypothesis, having the appearance of correctness. If expe- 
rience show that the sulphites are beneficial in the treatment of the 
so-called zymotic affections, we are then, and only then, justified in 
employing them. In our present imperfect knowledge of pathology 
and of the action of medicines, theorizing should succeed observa- 
tion. It is difficult to determine the exact value of any medicine 
in the treatment of zymotic diseases, since so many cases terminate 
favorably without medicines, but some of the physicians of this 
city who have used the sulphites speak favorably of their effect. 
My own experience with them has been limited. I have seen im- 
provement in severe scarlet fever when these agents were employed 
but remained in doubt whether the same result would not have fol- 
lowed with the use of other measures. The most eligible of the 
sulphites is the bisulphite of soda, since this gives a large amount 
of sulphurous acid, has no purgative effect, like some of the sul- 
phites, or other injurious action, and, from its name, insures against 
any mistake on the part of the druggist. The word sulphite has 
been mistaken in a prescription for sulphate, the error not being 



244 DIPHTHERIA. 

detected till the child was weakened by purgation. Bisulphite of 
soda is readily soluble in water as well as alcohol, and to a child of 
three to five years one to two drachms may be given in twenty- 
four hours, in doses of -Q.Ye to ten grains. 

E. Sodas bisulphit. gj-ij ; 
Tinct. aurant. sjij ; 
Aquae 5x. Misce. 
Dose, one teaspoonful every two hours. Sometimes in place of water a bitter 
infusion like that of quassia has been employed. 

Death in diphtheria, as we have seen, ordinarily occurs from ex- 
haustion or from obstructed respiration. Knowledge of this fact 
aids in the choice of therapeutic measures. Diphtheria is decidedly 
an asthenic disease; therefore sustaining treatment is required. 
From the first, although the pulse is strong, the surface hot, and 
features flushed, all measures of a depressing nature must be care- 
fully avoided. Great febrile excitement, in connection with robust- 
ness of system, may incline us to the use of cardiac sedatives, but 
they should not be administered, or if administered, only the mild- 
est should be given and with caution, since diphtheria, if it con- 
tinue a few days, is attended by evident symptoms of prostration, 
whatever the mode of commencement. Nutritious food, like the 
animal broths, should be given often and in a concentrated form, 
on account of the difficulty of swallowing, and recourse should be 
had to alcoholic stimulants, as wine-whey or milk-punch, as soon 
as there are any indications of feebleness. An extensive pseudo- 
membrane and great glandular swelling show a form of the disease 
which requires immediate and active sustaining measures. The 
apartment occupied by the patient should be kept clean and dry, as 
indeed it should be in the treatment of any infectious disease. A 
change of apartments during the day is also advisable, particularly 
in those cases in which there is a gangrenous odor. 

As the sulphites have not been employed sufficiently long to de- 
termine their value, or whether, indeed, they have any effect in 
controlling diphtheria, it does not seem judicious until they are 
more fully tested, and are found to accomplish what is claimed for 
them on theoretical grounds, to discard, in cases that are at all 
critical, those remedies which appear to be indicated from the 
nature of the disease, and which have met general approval of the 
profession. These remedies are the tonics, vegetable and ferrugi- 
nous. 

A large number of these medicinal agents might be mentioned, 
all of which would be likely to result in more or less benefit, but 



TREATMENT. 245 

I will only mention such combinations as are well adapted to meet 
the various indications. 

Chlorate of potash or soda, and tincture of the chloride of iron, 
are the two remedies which have been most employed in this country 
and in Europe, on account of their supposed local effect on the 
inflamed surface, and the latter on account of its eminently tonic 
properties. Prescribed in combination, these medicines are not 
unpleasant to the taste, and I consider this mixture one of the very 
best for ordinary cases of diphtheria: — 

R. Tinct. ferri chloridi 3J ; 
Potas. chlorat. 5j ; 
Syr. simplic. 3ij. Misce. 
Dose, one teaspoonful every two or three hours to a child of three years. 

I have usually given directions to allow no drinks to the patient 
for a few minutes after each dose, in order that the full local effect 
may be obtained. The tincture of the chloride of iron alone, the 
wine of iron, or any of the other ferruginous preparations, may be 
advantageously administered, especially in anaemic cases, in place 
of the mixture mentioned above. In those of full habit and florid 
complexion, iron is not so imperatively required. In such cases 
the elixir of Calisaya bark, in doses of one teaspoonful to a table- 
spoonful, according to the age, is a useful and not unpleasant 
remedy. The fluid extract of cinchona or columbo also meets the 
indication. 

There is difference of opinion as regards the value of local treat- 
ment in diphtheria. Some hold that as it is a constitutional 
malady, and that as death in it is ordinarily due either to exhaus- 
tion or to inflammation of the larynx, which we cannot subject to 
any reliable local treatment, therefore topical measures directed to 
the throat, which worry and fatigue the child, are not advisable. 
But, as Trousseau has remarked, the gravity of diphtheria is usu- 
ally proportionate to the amount of local disease, and if, therefore, 
we can moderate the intensity of the inflammation, we increase the 
chances of a favorable issue. The local disease reacts on and intensi- 
fies the constitutional, increasing the febrile movement, and ex- 
hausting the strength of the patient. Again, it is probable, though 
this opinion is not held by some, that the laryngitis of diphtheria 
often results from extension downward of the faucial inflammation. 

For these reasons, direct treatment calculated to diminish the 
intensity of the faucial inflammation is proper, and yet those severe 
caustic applications, formerly much employed, and still used by 
some practitioners, by causing great pain and restlessness, weaken 



246 _ DIPHTHERIA. 

the child, and do more harm than good. Great gentleness on the 
part of the physician, in making applications to the throat, cannot 
be too strongly insisted on. Harshness towards a patient is always 
to be condemned, and in no disease more than in this. By gentle- 
ness and a little tact, much of the repugnance to the operation, on 
the part of friends, may be prevented. 

The formulae recommended in the topical treatment of the larynx 
in croup are proper for the pharynx as well as larynx in diphtheria. 
For these formulae the reader is referred to the article on croup. 
The tincture of the chloride of iron has been advantageously 
prescribed as a gargle with chlorate of potash in those old enough 
to employ such treatment. For this purpose a drachm of the tinc- 
ture should be added to a tablespoonful of a saturated solution of 
chlorate of potash, and gargled every hour or two. I prefer, how- 
ever, a gargle consisting of carbolic acid, six or eight drops to one 
ounce of solution of chlorate of potassa, particularly if there is 
decomposition of the pseudo-membrane and an offensive odor. The 
local treatment should, of course, vary according to the extent and 
character of the inflammation. "When the pseudo-membrane is 
removed, and the inflammation has begun to abate, there is less 
need of active topical measures. They should soon be discontinued. 

When croupy cough is observed in diphtheria, it is well to 
administer, if the patient is robust, an emetic which causes the 
least possible prostration. The sulphate of copper or of zinc is 
one of the best emetics of this class. At the same time general 
sustaining treatment is required. Quinine is given by many prac- 
titioners when croup supervenes, in sufficient quantity to reduce 
the frequency of the pulse. A child from three to five years old 
may take a grain every two hours. I know no better medicine 
for such cases, though, unfortunately, with this or any other treat- 
ment, a large proportion die. Moisture in the apartment is desira- 
ble, as in the treatment of true croup. If the laryngeal symptoms 
continue to increase, and the respiration becomes so embarrassed 
that lividity occurs, the propriety of tracheotomy becomes a serious 
consideration. It is only in exceptional cases that it saves life, but 
it renders death more easy. 

If the patient has passed through diphtheria, and entered upon 
convalescence, attention should be given to his hygienic condition, 
and often therapeutic measures of a tonic character are still re- 
quired. That most interesting and important of the sequelae, 
namely, paralysis, gradually abates, without special treatment, as 
the tone of the system is restored. Strychnine may be given or 



PERTUSSIS. 247 

the galvano-electric current employed, as a means of expediting 
recovery. The following will be found a good formula for those 
affected with paralysis: — 

fy. Strychnia gr. j ; 

Acid, phosphor, dilut. 5*j ; 
Syr. zing-ib. ^vj. Misce. 
Dose, three to five drops in a dessertspoonful of water three times daily to a 
child of three years. 

The anaemic state which succeeds diphtheria requires the use of 
iron for several weeks. 



CHAPTER II. 

PERTUSSIS. 

Pertussis, or hooping-cough, is a contagious disease. It is 
manifested by inflammation of the mucous membrane of the air- 
passages, and a spasmodic cough to which this inflammation gives 
rise. It is due to a specific cause, a materies morbi, the exact nature 
of which is not known. It may occur both in the epidemic and 
sporadic form. It is probably not inoculable, although it is highly 
infectious, either through the breath of the patient, or by exhala- 
tions from his surface. With rare exceptions, it affects the same 
individual but once. Rilliet and Barthez report a case of its 
second occurrence, and a case is also reported by Dr. West. I have 
never attended a patient in two attacks, though I can recall to 
mind two individuals, both women of intelligence, who stated that 
they had previous attacks in early life. It occasionally affects 
young infants, even those less than one month old ; and, on the 
other hand, adults, and rarely even old people ; but most cases are 
between the ages of one and seven years. 

Symptoms. — Pertussis consists of three stages: first, the ca- 
tarrhal ; secondly, the stage of spasmodic cough — or, for brevity, 
the spasmodic stage ; thirdly, the stage of decline. 

The first period is characterized by the symptoms of coryza and 
bronchitis. The eyes present a moderately suffused and injected 
appearance. There is sneezing, with defluxion from the nostrils ; 
and there is also more or less cough, dependent on bronchitic in- 
flammation. The cough does not differ in character from that in 
the first stages of simple bronchitis, and there is little or no ex- 



248 PERTUSSIS. 

pectoration. Trousseau has known the cough to be repeated forty 
or fifty times per minute ; but such great frequency is rare. The 
pulse and respiration are moderately accelerated, and such other 
symptoms as commonly accompany inflammatory affections of a 
mild grade are present, namely, increased heat of surface, thirst, 
and impaired appetite. 

The duration of the first stage is various. It may, in rare in- 
stances, last only two or three days ; or, on the other hand, be pro- 
tracted even to six weeks. Its ordinary duration is from eight to 
fifteen days. In fifty-five cases observed by Dr. West, its average 
duration was twelve days and seven-tenths of a day. I have met 
two cases, both girls over the age of six years, in whom no spas- 
modic cough was noticed. If there was any, it was limited to a 
few paroxysms, and it might, therefore, be said that there was but 
one stage, namely, the catarrhal. They had the symptoms of the 
catarrhal stage, but instead of the occurrence of the spasmodic 
cough at the usual period, the inflammatory symptoms abated 
somewhat, and there remained an occasional easy cough, like that 
of simple subacute bronchitis. This continued during a period 
which corresponded with the duration of pertussis. The diagnosis 
in these cases would have been doubtful, except for the simultane- 
ous occurrence of pertussis, with its regular stages, in other children 
of the same families. 

Second Period. — This supervenes gradually. At first, while the 
cough ordinarily has the character presented in the first stage, it is 
now and then observed to be more severe and spasmodic. The 
spasmodic element increases gradually, so that in the course of a 
week all doubt as to the nature of the disease, if any previously 
existed, is removed. 

The severity of the cough in the second stage varies considerably 
in different cases. It sometimes occurs quite abruptly, but com- 
monly there is premonition of it. The patient endeavors to re- 
press it. If a child, he leaves his playthings, and rests his head on 
his mother's lap, or takes hold of some firm object for support; his 
face has a grave or even anxious appearance, while the pulse and 
respiration are somewhat accelerated. Immediately the cough 
commences. It consists in a succession of short and hurried expi- 
rations, which expel a large part of the air contained in the lungs, 
followed by a rapid and deep inspiration. There may be a single 
series of expirations, terminating in the manner mentioned ; but 
often there are two, three, or more such series embraced in a 
paroxysm. The paroxysm commonly ends in the expulsion of 



SECOND PERIOD. 249 

froth v mucus from the bronchial tubes, and sometimes in vomiting. 

«/ i CD 

The rapid passage of air through the glottis, in the inspiration 
which terminates the cough, is sometimes accompanied by a sound, 
which is called the hoop. During the cough there is temporary 
arrest of blood in the lungs, leading to congestion in the right cavi- 
ties of the heart and throughout the systemic circulation ; there- 
fore the face is flushed and swollen, and occasionally hemorrhage 
occurs under the conjunctiva, or from one of the mucous surfaces. 
The most frequent hemorrhage is epistaxis. "When the cough 
ceases, and normal respiration is restored, the fulness of the vessels 
immediately abates ; but often puffiness of the features is observed, 
due to serous infiltration of the subcutaneous cellular tissue, and 
continuing for days or weeks during the period when the cough is 
most severe. 

The paroxysm lasts from a quarter to a half or even a whole 
minute, and in that time, in severe cases, there are often as many 
as fifteen to twenty series of expirations. The hoop is not as loud 
in infants as in children, and in young infants, especially those 
under the age of six months, it is often lacking, although the cough 
may be severe. 

At the close of the paroxysm, if there is no complication, the 
symptoms soon abate ; the temperature, pulse, and respiration 
become normal, and there is no evidence of disease. The cough in 
the second stage is much more frequent in one case than another. 
At the height of this stage it is generally more severe if it occurs 
at long intervals than when frequent. During the weeks in which 
pertussis is most severe there is, in the average, about one paroxysm 
of coughing to each hour. 

The cough increases in severity till the third week of the second 
stage, or the thirtieth to thirty-fifth day of the disease, after which 
it remains stationary for a certain time. It is apt to be more 
frequent in the night than daytime. Sometimes it occurs while 
the child is quiet ; it may even awaken him from sleep, but it is 
often also produced by mental excitement or by physical exertion. 
Anger or fright gives rise to it, and therefore the child is apt to 
cough when being examined by the physician, or when his wishes 
are not complied with. The ordinary duration of the second stage 
is from thirty to sixty days. It may, however, be considerably 
longer or shorter than this. 

The third stage, which commences at the time when the spas- 
modic cough begins to abate, is short, not continuing longer than 
two or three weeks. A protracted stage of decline indicates some 



250 PERTUSSIS. 

complication. While the sputum in the second stage is mucous 
and frothy, that in the third stage is more opaque and puriform. 

In the third as in the second stage, if there is no complication, 
the pulse and respiration in the intervals of the paroxysms are 
nearly or quite natural. Febrile excitement may, however, now 
and then occur from trifling causes, or, indeed, without any appa- 
rent cause. The digestion and the general health in uncompli- 
cated pertussis remain unimpaired, with the exception of more or 
less emaciation, which is apt to occur in all hut the mildest cases, 
in consequence of the frequent vomiting. After complete recovery, 
it is not unusual for the spasmodic cough to reappear, at times, for 
one or even two years. The cough of ordinary simple laryngitis, 
or bronchitis, assumes this character. 

Complications. — These, like the symptoms, are chiefly of a two- 
fold character, namely, inflammatory and neuropathic. From the 
nature of the cough in this disease, it would naturally be supposed 
that the spasmodic affection, which is now designated internal 
convulsions, and which is characterized by spasm of certain muscles 
of respiration, would be a frequent complication. It does sometimes 
occur in young children, but it is not common. Clonic convulsions 
affecting the external muscles are, on the other hand, not infre- 
quent. They occur chiefly in the second stage, when the cough is 
most severe, and in infancy much more frequently than in child- 
hood. They are apt to be general and severe, or, if not of this 
character at first, to become such. The convulsions commence, in 
most instances, in or directly after the paroxysm of coughing ; but 
they sometimes occur in the interval when the child is quiet. 

Eilliet and Barthez remark: "Almost all infants succumb to 
this complication, ordinarily in the twenty-four hours which follow 
the first attack ; nevertheless, life may be prolonged during two or 
three days" (Article Coqueluche). In my own practice this compli- 
cation of hooping-cough has usually terminated fatally, but I have 
known recovery to occur somewhat unexpectedly under the use of 
bromide of potassium. In the month of June, 1867, 1 was attend- 
ing a little girl two years and four months old, who had reached 
the fifth week of pertussis, when she was seized with general clonic 
convulsions. The mother, who was requested to keep a record of 
the number of convulsions, stated that there were twenty in all, 
occurring within forty-eight hours. They affected both sides, the 
shortest lasting only three or four minutes, the longest seventy-five 
minutes. The treatment in this case, which eventuated favorably, 
will be noticed hereafter. 



COMPLICATIONS. 251 

In those who die of convulsions occurring in hooping-cough, 
the most constant lesion is congestion of the cerebral veins and 
sinuses, often with transudation of serum. This congestion is due 
in part to the cough which precedes the convulsions, and in part £o 
the convulsions themselves. At the autopsies which I have made 
of two infants, who died in hospital practice from hooping-cough, 
accompanied by convulsions, all the cerebral sinuses were filled 
with clots, which were generally soft and dark ; but in the lateral 
sinuses clots were found, which were light-colored. The light 
color of a clot, either in a vein or sinus, indicates its ante-mortem 
formation. 

The gravity of the convulsive attack can be ascertained by ob- 
serving whether the patient readily recovers consciousness. Its 
return indicates that there is no serious congestion. On the other 
hand, great drowsiness remaining, or a semi-comatose state, indi- 
cates persistent congestion, and perhaps even the formation of clots 
in the sinuses of the brain. Death from convulsions is usually 
preceded by coma. Occasionally meningeal apoplexy supervenes 
upon the congestion, and death is immediate. 

The most frequent inflammatory complications are bronchitis 
and pneumonitis. Inflammation of the larger bronchial tubes, we 
have seen, is a common accompaniment of pertussis, but when it 
extends to the minuter tubes, or becomes so severe as to cause 
acceleration of respiration, it is, properly, a complication. Both 
bronchitis and pneumonitis, occurring as complications, are de- 
veloped, with few exceptions, in the second stage. Bronchitis 
is accompanied by accelerated respiration and pulse, and increased 
temperature. The danger is proportionate to the amount of 
dyspnoea. 

Pneumonitis is a less common complication than bronchitis, but 
it occurs more frequently in pertussis than in any other constitu- 
tional affection of early life, excepting measles. The congestion, 
which occurs and remains in the lung when the cough is frequent 
and severe, favors the development of pneumonia. The symptoms 
and physical signs which accompany this inflammation and serve 
for its diagnosis are the same as in the primary form of the dis- 
ease, and are described elsewhere. Bronchitis or pneumonia usually 
moderates the severity of the spasmodic cough, for when the inflam- 
matory element in pertussis increases, the spasmodic abates. On 
the abatement of the inflammation, however, the cough usually 
regains its former convulsive character. The fact may be stated 
in this connection, that any complication or intercurrent disease, 



252 PERTUSSIS. 

which is attended by decided febrile reaction, ordinarily renders 
the cough for the time less spasmodic. 

The occurrence of bronchitis or pneumonia is shown by the 
elevated temperature, acceleration of pulse and respiration, short 
and frequent cough. These symptoms do not cease as long as the 
inflammation continues, whereas in uncomplicated pertussis the 
patient seems nearly or quite well between the coughs. In pneu- 
monia the respiration is accompanied by the expiratory moan, and 
in both bronchitis and pneumonia there is more or less depression 
of the infra-mammary region during inspiration. These symptoms, 
in connection with the physical signs, render diagnosis in most 
instances easy. Although the general character of the cough is 
changed, a cough now and then occurs, even when the inflamma- 
tion is pretty severe, sufficiently spasmodic to indicate the nature 
of the primary affection. Capillary bronchitis and pneumonia are 
always serious complications. 

It is stated by certain writers that the spasmodic cough of per- 
tussis occasionally gives rise to emphysema, and dilatation of the 
bronchial tubes. Billiet and Barthez do not believe that these 
structural changes occur from such a cause, because the spasmodic 
character of the cough of pertussis pertains to expiration. Later 
observations, however, demonstrate that emphysema in certain 
cases does result from forcible expirations (Niemeyer and others). 
Emphysema is a common lesion in young and feeble infants, even 
when there is no history of any previous severe disease of the 
respiratory organs. I have found it one of the most common lesions 
in infants of feeble constitutions who die in the Infant's Hos- 
pital and Nursery and Child's Hospital of this city. The chief 
cause of the emphysema in these cases appears to be the impaired 
nutrition and change in the molecular condition of the tissues. 
The same condition arises in severe and protracted pertussis, in 
which the child becomes enfeebled and cachectic. If severe bron- 
chitis arises, we have still another factor in the production of 
emphysema. 

At the meeting of the New York Pathological Society, October 
14th, 1868, I exhibited emphysematous lungs removed from an 
infant who died at the age of nineteen months, and at the com- 
mencement of the fourth week of pertussis. Death occurred from 
thrombosis in the lateral sinuses of the cranium, resulting from 
the severe spasmodic cough, clonic convulsions, and from feebleness 
of the circulation, as the infant was previously in a reduced state 
from chronic entero-colitis. At the autopsy the superior lobes of 



DIAGNOSIS. 253 

both lungs were found exsanguine, doughy to the feel, and enlarged 
so as to rise above the level of the other lobes. The resiliency of 
the elastic tissue of these lobes was evidently greatly impaired, 
and their air-cells in a state of over-distension. The other lobes 
were healthy, except that one of them was the seat of lobular 
pneumonia. In the history of this case it did not appear that 
there had been any pathological state affecting the respiratory 
system previously to the pertussis, so that the commencing emphy- 
sema was referable to this disease. The forcible and irregular res- 
pirations which accompany the cough of pertussis appear, there- 
fore, sufficient for the production of emphysema in the infant. 

I have occasionally met cases in which partial collapse of certain 
portions of the lungs had occurred, and the mechanism of the cough 
is such that this would be a more probable result than enlargement 
of either the tubes or air-cells. Collapse, like emphysema, may 
continue for weeks or months subsequently to pertussis, and then 
gradually disappear. 

Diagnosis. — During the period of invasion it is impossible to 
diagnosticate pertussis. Its nature can only be conjectured from a 
known exposure, or from the epidemic occurrence of the disease. 
In the second stage, which is characterized by the spasmodic 
cough, diagnosis is ordinarily easy, and often the parents are able 
to announce the nature of the disease when the physician is called. 
Still, a mistake is sometimes made: a spasmodic cough very similar 
to that of pertussis occasionally occurs in other maladies. Young 
infants with bronchitis frequently experience great difficulty in 
the expectoration of mucus, which collects in the air-passages and 
provokes a suffocative cough. The following facts will aid in 
making the diagnosis. Bronchitis, accompanied by a suffocative 
cough, is an acute disease, and the cough occurs at an early period, 
usually in the first week. It lacks the inspiratory sound or the 
hoop, and is associated with constantly accelerated respiration and 
well-marked febrile symptoms, dependent on the inflammation. 
Moreover, the cough is only occasionally suffocative, according to 
the amount of mucus in the tubes. The spasmodic cough of per- 
tussis, on the other hand, is preceded by the stage of invasion. 
This cough occurs in the second stage, when the febrile symptoms 
have abated; if the disease is uncomplicated, it is accompanied by 
a hoop, and its ordinary character is spasmodic. Again, the suffo- 
cative cough of bronchitis rarely ends in vomiting, which has been 
seen to be so common in the cough of pertussis. 

The only other disease with which there is much likelihood of 



254 PERTUSSIS. 

confounding pertussis is bronchial phthisis. The points of differ- 
ential diagnosis are the following: the one epidemic, and spreading 
by contagion ; the other non-contagious, and isolated : the one em- 
braced in three distinct stages, and much shorter ; the other chronic, 
and presenting no stages, but commencing with mild non-febrile 
symptoms, and progressively becoming more severe : in the one an 
absence of symptoms in the intervals of the cough, provided there 
is no complication; in the other constant symptoms, such as are 
common in tubercular disease. The previous health, and the pre- 
sence or absence of a tubercular cachexia, should be considered in 
determining the nature of the disease, and usually, in bronchial 
phthisis, the lungs are also affected, so that auscultation and per- 
cussion may furnish positive proof of the nature of the cough. 

Prognosis. — This is ordinarily favorable. Nearly all recover, 
unless some complication arises. In rare instances death may occur 
in or immediately after a paroxysm of coughing, in consequence 
of the rupture of cerebral capillaries, and the occurrence of apo- 
plexy. Most fatal cases, however, are complicated w T ith either 
clonic convulsions, bronchitis, pneumonia, or, in the summer season, 
entero-colitis, and death is due to the complication rather than the 
pertussis. It has been stated elsewhere that clonic convulsions 
render the prognosis unfavorable, but the case detailed above shows 
that some may recover. If the convulsion is succeeded by marked 
drowsiness, the prognosis is very unfavorable. It is probable that 
other convulsions will occur, ending in coma. Immediate recovery 
of consciousness shows a less dangerous form of convulsions, and 
one which, with proper treatment, may terminate favorably. 

The danger in bronchitis and pneumonia depends on the extent 
of the inflammation, the amount of dyspnoea, the age and strength 
of the patient. Capillary bronchitis and pneumonia are always 
serious complications. They have been the cause of death in a 
large proportion of the fatal cases which I have attended. Per- 
tussis sometimes is attended with so much emaciation and loss of 
strengthen consequence of the vomiting, that intercurrent diseases, 
which, in favorable states of the system, would probably end favora- 
bly, are very apt to prove fatal. In this city epidemics of the diar- 
rheal affections, so common among infants in the summer, are much 
more fatal if at the same time there is an epidemic of pertussis. In 
my practice, an infant affected at the same time with the " summer 
complaint" and hooping-cough has generally perished, unless re- 
moved to the country. If there is much emaciation and an heredi- 



TREATMENT. 255 

tary tendency to tuberculosis, the prognosis is more unfavorable, 
on account of the probable occurrence of this disease. 

Treatment. — In the catarrhal stage the treatment should be the 
same as in idiopathic catarrh. It should consist of mild counter- 
irritation to the chest. If there is much bronchitis, with accele- 
rated breathing, the oil-silk jacket may be applied. Demulcent, 
laxative, and gentle expectorant mixtures are proper. Care should 
be taken to employ nothing which would reduce the strength, or 
in any way impair the general health. 

Therapeutic measures are most beneficial in the second stage, or 
that of convulsive cough. Proper treatment may prevent or con- 
trol complications, which arise chiefly in this stage, and may mod- 
erate the intensity of the cough. Many formulae have been recom- 
mended for the treatment of pertussis, most of them containing 
some antispasmodic. Oxide of zinc, musk, assafcetida, valerian, 
cochineal, the anaesthetics, and many other medicinal agents, have 
been employed, and there are physicians with whom each of these 
has had its season of repute. The three medicines which are most 
in favor with the profession, both in this country and Europe, and 
properly so, are hydrocyanic acid, balladonna, ancL bromide of am- 
monium. The employment of the last of these is comparatively 
recent. The others are old remedies, and their therapeutic effects 
are more fully ascertained. In my opinion, the treatment by bella- 
donna is usually most successful, and this agent is more employed 
than any other. Some of the belladonna of the shops, as is true 
likewise of hydrocyanic acid, is of inferior quality, either from its 
mode of preparation, or the manner in which it has been kept, and 
is therefore not reliable. But if good, and prescribed properly, it 
will ordinarily render the cough milder. 

The first dose of belladonna should be smaller than will probably 
be required to ameliorate the disease. The child, however, requires 
a larger proportionate dose of belladonna than an adult to produce 
the same effect. Trousseau's great experience in the treatment of 
children's diseases, and his successful practice, render his views in 
reference to the employment of this agent deserving of careful con- 
sideration. For young children he directed pills to be made, each 
containing about one-tenth of a grain of extract of belladonna 
mixed with an equal quantity of the powder of the leaves of bella- 
donna. 

For children over the age of four years, the pills contained one- 
fifth of a grain of the extract and the same quantity of the powder. 
He directed that one of these pills should be taken in the morning 



256 PERTUSSIS. 

when the stomach was empty, and a second on the following morn- 
ing. The nurse marked on a card each paroxysm of coughing, so 
that the effect of the medicine could be ascertained. If the number 
of paroxysms was diminished, or the cough rendered less severe, 
so that there was evidently decided amelioration, the same dose 
was administered each day. If, on the other hand, there was no 
improvement in the number or severity of the paroxysms, two pills 
were given on the following morning, three on the next, and so on 
till an appreciable effect was produced. Trousseau considered it 
important to give at one dose whatever belladonna is administered 
during the day. The same quantity per day given in small doses, 
at intervals, he believed to be less effectual. 

The dose which he found to produce amelioration of the symp- 
toms he ordered to be repeated daily during the succeeding six or 
eight days. Then, if the improvement continued, the dose was 
gradually diminished by one pill each day, back to the first dose ; 
but if the cough increased, the dose was again increased. 

Finally, when the spasmodic cough had entirely ceased, Trous- 
seau advised the continuance of the medicine six or eight days 
longer before its complete suspension. 

Trousseau sometimes employed atropine in place of belladonna, 
since the medicinal properties of the plant reside in this alkaloid, 
and, being crystalline, its strength is always uniform. He gave 
the neutral sulphate of atropia in dose of about y^ part of a grain, 
dissolved in distilled water, to infants or young children, in the 
same manner as he prescribed belladonna. For older children he 
ordered a dose proportionately larger. Brown-Sequard, in remarks 
made before the United States Medical Association in May, 1866, 
maintained that the duration of pertussis, so far as the neuropathic 
element is concerned, might be abridged to a few days by doses of 
atropia sufficiently large to produce toxical effects. He recom- 
mends a dose which will cause, and repeated will maintain, deli- 
rium for three days; after which, he states, the cough is no longer 
spasmodic. 

The older physicians who first advised the employment of bel- 
ladonna in pertussis, as Schaeffer, Guersant, Goelis, and Wendt, 
used it with caution, and in small or moderate doses, apparently 
believing that its use involved considerable danger. It is now, 
however, considered a safe as well as efficient remedy, and it is 
admitted that in pertussis the full benefit of the drug can only be 
obtained from doses which produce a decided impression on the 
system. If there is no amelioration of symptoms from smaller 



TREATMENT. 257 

doses, it is proper to give it in a quantity which will cause dry- 
ness of the fauces and efflorescence upon the skin. 

The tincture of belladonna is most convenient for use. The doses 
which I have found to he sufficient to modify the cough, at the 
same time producing efflorescence, are as follows: To a child of two 
years three drops, to one of six to eight years ten drops, morning 
and evening. I always commence, however, with a smaller dose, 
and continue to administer for a few days the dose which is found 
to produce the local effects alluded to. In the majority of cases 
I have noticed no decided effect till the rash was produced, when 
the symptoms improved, the cough becoming either less frequent or 
less severe. I have by means of this treatment been able to curtail 
the duration of the disease to four weeks from the beginning of 
the catarrhal stage, even when the paroxysms were unusually 
severe. The dose which proves sufficient to control the disease 
should be administered daily for a time, and then gradually di- 
minished as the cough declines. Hydrocyanic acid possesses the 
power of controlling the spasmodic cough of pertussis. It is re- 
commended by Dr. West. " I usually begin," says he, " with a 
dose of half a minim of the acid of the London Pharmacopoeia 
(that of the U. S. Ph. is the same) every four hours for a child nine 
months old ; and so in proportion for older children. The specific 
influence of the remedy is, I think, both more safely and efficiently 
exerted by increasing the frequency of its administration than by 
adding to the dose, and I should therefore prefer to give half a 
dose every two hours, rather than to double the dose without in- 
creasing the frequency of its repetition. This remedy sometimes 
exerts an almost magical influence on the cough, diminishing the 
frequency and severity of its paroxysms almost immediately ; while 
in other cases it seems perfectly inert." Dr. "West has employed 
this remedy several hundred times, and only once has observed 
alarming symptoms from its use. The patient was two and a half 
years old, and had been ordered one minim of the dilute acid 
every four hours. He took the acid for four days without any 
effect being produced, either on his system generally, or on the 
cough ; but at the end of that time, after taking the close, he ut- 
tered a cry, became quite faint, and would have fallen, if not sup- 
ported. 

Hydrocyanic acid, given in safe doses, does not appear to pro- 
duce amelioration of symptoms in so large a proportion of cases as 
belladonna, and I do not know any advantages which it possesses 
over that agent. Belladonna never produces sudden alarming 
17 



258 PEETUSSIS. 

symptoms, like the acid. If, through mistake, more than the pre- 
scribed quantity is administered, it may cause delirium, and the 
characteristic effect on the mucous membrane of the fauces and 
upon the skin; but a gradual disappearance of these symptoms 
may be confidently expected, without any injury to the patient. 
Even poisonous doses, unless excessive, are rarely fatal. If for any 
reason it is thought best to prescribe hydrocyanic acid, the fol- 
lowing formulae from West may be employed: — 

R. Acid, hydrocy. dil. "nUv ; 
Syrupi shnplicis £j ; 
Aquae destillat. 5vij. M. 
A teaspoonful to be taken every six hours by a child nine months old. 

&. Acid, hydrocy. dilut. riyv ; 
Mistur. amygdalae Jj. M. 
Dose the same. 

The bromides have, within a few years, been used in the treat- 
ment of pertussis. They were first recommended by Dr. Gibbs, 
and subsequently by Prof. Harley, of London. It is claimed for 
them that they produce an anaesthetic effect on the mucous mem- 
brane of the larynx. The bromide employed by the above and 
other physicians has commonly been that of ammonium, but 
some prescribe that of potassium, or the two in combination. 
Prof. Harley gives one grain of the bromide of ammonium for 
each year of the patient's age, three times daily ; Dr. Gibbs gives 
two or three grains every eight hours to infants, and from four to 
ten grains to older children. Dr. Ritchie, physician to the Royal 
Edinburgh Hospital for Sick Children, says of it (Edin. Med. Journ. y 
June, 1864): "In my experience, the remedy appears to be most 
successful in children whose age exceeds two years. . . . The quan- 
tity I have generally given has been from three to twelve grains 
a day, in divided doses, administered every six hours. . . . Having 
used the preparation in upwards of twenty cases, if I may be 
allowed to express an opinion on this head, it would be that the 
great efficacy of the drug is in uncomplicated cases ; that in those 
complicated with acute bronchitis, or pneumonia, the benefit is so 
trifling that I prefer other methods of treatment; for an acute 
congested condition of the air-passages appears to lessen the effect 
of the bromide as a laryngeal anaesthetic; that the more frequent 
the paroxysms of hooping, the more marked and rapid is the relief; 
that greater relief appears to be experienced in those of some 
continuance than in recent cases ; and, lastly, that when chronic 
bronchitis is present, the bromide should not be given alone, but 



TREATMENT. 259 

combined with squill and ipecacuanha mixture, and occasionally 
with an emetic." 

I have employed the bromides, though not largely, in the treat- 
ment of pertussis, but have not, in ordinary cases, observed that 
benefit which I had been led to expect. In recent cases, belladonna 
is a much more efficient remedy. I would use the bromides chiefly 
in advanced cases, and in cases, whatever the period of pertussis, 
in which there seems to be imminent danger of clonic convulsions. 
In these last cases, the bromide of potassium, with or without 
that of ammonium, may, in certain cases, prevent the convulsive 
seizure. The hydrate of chloral has been employed for pertussis, 
in the children's class, in the out-door department at Bellevue. 
It produces prolonged sleep, and consequently diminishes the fre- 
quency of the cough as long as the narcotic effect lasts, otherwise 
it does not seem to exert any influence on the symptoms or progress 
of the disease. 

There are many other remedies which have been vaunted in the 
treatment of pertussis, and which do moderate the severity of the 
cough. Some, it seems to me, have this effect by producing febrile 
excitement. Such is the use of cantharides, so as to produce active 
congestion of the urinary passages and strangury ; severe counter- 
irritation over the chest by tartar emetic, namely, Autenneth's 
treatment, etc. Emetics have sometimes been prescribed in the first 
stage of pertussis, in the belief that they moderated the severity 
of the disease. They are more frequently employed on the Conti- 
nent than in this country. Laennec says: "Not any measure is 
more useful in the commencement of pertussis than vomiting, 
repeated every day or every two days, during one or two weeks." 
Some physicians have given for this purpose ipecacuanha, and 
others sulphate of zinc. Trousseau employed sulphate of copper. 
The loss of strength, however, which necessarily attends the em- 
ployment of emetics, even the mildest, more than counterbalances 
any good effect of their use, excej3t when there is considerable 
accumulation of mucus in the tubes, which an emetic assists in 
expelling. 

A remedy long in use, and still a favorite with many families, 
consists of half a scruple of cochineal, one scruple of carbonate of 
potassa, one drachm of sugar, and four ounces of water. The dose 
for a child one year old is a dessertspoonful three times daily; for 
older children the dose is increased in a corresponding degree. It 
is believed by some that the cochineal is inert, and that the bene- 



260 PEETUSSIS. 

ficial effect of the above mixture is due to the potassa, which 
modifies the accompanying bronchitis. 

Alum, in doses of one to six grains, according to the age, is 
recommended by Dr. J. F. Meigs {Treatise on Diseases of Children). 
Inhalation of the fumes arising from the purification of gas, has 
been recommended in Paris as an effectual remedy in the declining 
stage of pertussis ; but, on the other hand, it is alleged that the 
benefit is due to the out-door exercise required by this treatment. 
M. Roger employed these furies in the wards of the Children's Hos- 
pital, Paris ; but apparently without benefit. Nitric acid has also 
been used internally, and applications of nitrate of silver to the 
throat; both, it is stated, with improvement in certain cases. 
Change of air is always beneficial in advanced hooping-cough. In 
uncomplicated cases the child should be carried daily into the open 
air; but, on account of the inflammatory affection of the air-pas- 
sages, should never be exposed to cold or wet, or sudden changes of 
temperature. For the same reason the temperature of the apart- 
ment should be moderately warm and uniform. Great benefit, as 
regards the severity of the cough, often accrues, especially in the 
advanced period of the disease, by removing the child to the coun- 
try, or to another locality. 

Severe bronchitis, or pneumonia, which often complicates per- 
tussis, requires the treatment which is elsewhere recommended for 
the secondary form of this inflammation, namely, the use of the 
oil-silk jacket, poultices, counter-irritation, and, internally, carbon- 
ate of ammonia, with perhaps a tonic. As mild bronchitis is present 
from the commencement of the disease, the oil-silk jacket is useful 
even before the inflammation becomes so severe as to constitute a 
complication. Clonic convulsions, which we have seen are a com- 
mon and very serious complication, should be treated by cold to the 
head, a warm foot-bath, and laxatives in certain cases. The medi- 
cine which, in my opinion, is most likely to control the spasmodic 
movements, is bromide of potassium. The mode of administering 
this agent will be sufficiently explained in our remarks relating 
to the treatment of eclampsia. In the case alluded to in the pre- 
ceding pages, in which there were twenty convulsions within forty- 
eight hours, and the patient, two years and four mouths old, 
recovered, the bromide of potassium was given in combination with 
the iodide. The dose was about two grains of each every two or 
three hours. 



PAROTIDITIS. 261 



CHAPTER V. 

PAROTIDITIS. 

Ordinarily, parotiditis, or parotitis, or mumps, lias no premo- 
nitory stage; but in exceptional cases, languor with fever pre- 
cedes the disease for a few hours. Mumps commences with ten- 
derness in the parotid region, followed soon after by tumefaction. 
The swelling gradually increases ; it fills the depression under the 
ear, extends forward and upward upon the cheek, and downward to 
a greater or less extent upon the neck. It has been demonstrated 
in case of symptomatic parotiditis, and the same is probably true 
of the idiopathic disease, or mumps (Yirchow), that the swelling is 
due to inflammation of the gland-ducts, and consequent oedema of 
the interstitial tissue. The inflammation is specific, due to a mate- 
ries morbi in the blood, and hence its decline after a fixed period. 
It reaches its maximum from the third to the sixth day. The 
most prominent point at this time is immediately underneath the 
lobule of the ear. The tumor, which is firm but slightly elastic, 
presses outward the lobule. In most cases the skin preserves its 
normal appearance over the swelling, but occasionally it presents 
a faint blush. The pressure which movements of the jaw produce 
on the gland renders mastication and even talking painful. Febrile 
movement more or less intense occurs, lasting, in ordinary cases, 
not more than forty-eight hours, but occasionally it is more pro- 
tracted. Vomiting and epistaxis are sometimes present. The 
swelling having attained its maximum size, remains stationary a 
short time, when it begins to decline, and by the sixth to tenth 
day it has entirely subsided. 

In most cases parotiditis is double ; it commences on one side, 
more frequently the left than right, and in from one to four days 
the opposite gland is involved. In those exceptional cases in 
which only one parotid is affected, the opposite gland may be the 
seat of the disease at some subsequent period. It has been estimated 
that the proportion of unilateral to double mumps is as one to ten. 

The total duration of this disease is usually from eight to ten 
days; in the mildest cases it may not be more than five days. 
The submaxillary glands are often involved in connection with the 
parotids, and sometimes also the sublingual, although, from their 



262 PAROTIDITIS. 

small size and concealed position, their tumefaction escapes notice. 
Karely the tonsils are also tumefied. Sometimes free perspiration 
occurs at the commencement of convalescence. 

The swelling of the parotids sometimes abates suddenly, and in 
the male the testicle, epididymis, and tunica vaginalis become 
inflamed ; while in the female, the mammary glands, ovaries, or 
the labia majora, are the seat of the so-called metastasis. Occa- 
sionally these inflammations, which are less frequent in young 
children than those near the age of puberty, when the sexual 
organs are becoming more developed, occur without subsidence of 
the parotid swelling. They cause considerable increase in the 
fever and constitutional disturbance, but with proper treatment 
decline in six to eight days, pursuing the same course as the parotid 
inflammation. 

Nature. — Parotiditis is contagious. It is rare in infancy and 
after the middle period of life, occurring chiefly in childhood, 
youth, and early manhood. An incubative period of about twelve 
days was ascertained by me in cases occurring in the Protestant 
Episcopal Orphan Asylum of this city. The observations of others 
give a similar result. Parotiditis is a blood disease, having the 
local manifestation described above, and which is our only means 
of diagnosis. 

Diagnosis. — If the physician has seen but few cases of mumps, 
there is danger that he may mistake the swelling for an inflamed 
cervical gland, or vice versa, but an inflamed cervical gland presents 
to the finger a hardness almost like that of cartilage, and it is cir- 
cumscribed or round, and does not invest the ear. These charac- 
teristics contrast with the elasticity, seat, and shape of the parotid 
swelling, which extends forward on the cheek, and surrounds and 
elevates the lobule of the ear. Tumefaction resulting from diph- 
theritic or any other form of faucial inflammation, or from peri- 
ostitis affecting the root of the posterior molar, may be detected by 
examining the fauces and interior of the mouth. 

Treatment. — This is very simple. Oakum or carded wool may 
be bound over the swelling, and the surface occasionally rubbed 
with sweet oil. Mild laxative, and diaphoretic drinks, such as 
bitartrate of potash or lemonade, are useful. If metastasis occur, 
the new local affection should receive chief attention. It should 
be treated in the same manner as if it occurred independently of 
the mumps. The employment of irritants over the parotid in order 
to cause a return of the inflammation from the sexual organ to this 
gland, does not have the effect desired, and is injurious. 



SECTION IY. 

OTHER GENERAL DISEASES. 



CHAPTER I. 

INTERMITTENT FEVER. 

Intermittent fever is a constitutional disease, due to a specific 
cause emanating from the soil. It spares no age. Even infants 
of a few months are not exempt from it, and it is said that a preg- 
nant woman affected with it occasionally observes a periodical 
tremor of the foetus. Stokes, of Dublin, recorded such a case; and, 
according to Bouchut, cases have been observed in which new-born 
infants, whose mothers were affected, had not only the characteristic 
paroxysms, but also enlarged spleens, showing that intra-uterine 
life is not always shielded from the influence of the specific cause. 

It is not fully ascertained whether a nursing infant may contract 
intermittent fever by lactation, but if it is admitted that it is some- 
times communicated to the foetus through the maternal circulation, 
it does not seem improbable that the specific principle occasionally 
enters the milk as well as other secretions. I have frequently 
remarked the presence of the disease in nursing infants whose 
mothers were affected, and in one instance an infant at the breast, 
whose mother had the ague, having contracted it in a suburban 
village, but was since living in a non-malarious part of the city, 
presented evident symptoms of the disease. Similar observations 
by Frank, Burdel, and others, do not indeed fully prove the com- 
municability of intermittent fever by lactation, but render it highly 
probable. 

ISTo ascertained facts relating to intermittent fever in children 
throw any light upon the remarkable and much discussed observa- 
tions and experiments of Prof. Salisbury, relating to the etiology of 
intermittent fever. Certainly, if the cause is a vegetable cell enter- 
ing the blood through respiration, it sometimes adheres to it most 



264 INTERMITTENT FEVER. 

tenaciously, and is probably reproduced in it, even under circum- 
stances favorable for its elimination. Thus, at one of my cliniques 
at Bellevue Hospital Medical College in 1871, a cbild ten years old 
was presented, who had had every year for seven years attacks of 
intermittent fever. The disease was contracted at the age of three 
years in Harlem, and the subsequent residence of the family had 
been in a part of the city where there was no malaria. 

Symptoms. — In infancy, and especially prior to the age of eighteen 
months, the symptoms differ in certain respects from those which 
characterize the disease in the adult, and are universally known. 
In childhood the symptoms are similar to those in the adult, and 
need not, therefore, be described in this connection. 

In the nursing infant the type is ordinarily quotidian, but now 
and then tertian. Advancing beyond the age of eighteen months, 
we meet more and more cases of the tertian type, and in childhood 
it is the common form. I have known the quotidian in the infant, 
when cured, to reappear a few weeks after as a tertian, but ordi- 
narily it remains quotidian unless the patient has reached the age 
at which the tertian type predominates. 

The paroxysm in the young infant presents three stages, as in the 
adult, but while the second, or febrile, is well marked, the first and 
third are much less pronounced. The patient does not shake (ex- 
ceptionally one does even within the first year) in the first stage, 
but a slight tremor may or may not be observed. The countenance 
presents a sunken appearance; the lips and fingers are livid, while 
portions of the surface not livid are pallid, with the goose-flesh .ap- 
pearance, which is, however, less marked than in children of a more 
advanced age. The blood leaves the surface, which consequently 
shrinks, while it accumulates in the veins and internal organs ; . the 
pulse is feeble, and readily compressed ; the surface grows cool from 
the diminished supply of blood, but the breath is warm, and the 
internal temperature, so far from being reduced, is elevated two or 
three degrees. The parents may be alarmed at the sudden sinking 
of the vital powers, and seek medical advice, but in other instances 
the first stage is so slight that it passes unperceived till they have 
been taught to watch for it, and the second stage first attracts 
attention. 

In the second or febrile stage, which immediately succeeds, the 
pulse becomes full and rapid, 120 to 130 or 140 beats per minute, 
and the external as well as internal temperature is elevated as in 
few other diseases (104°-108°). The face is flushed, surface dry, and 
head painful, as evinced by the features. This stage lasts about two 



SYMPTOMS. 265 

hours or somewhat longer. The third stage, or that of perspiration, 
succeeds, which terminates the suffering of the patient till the fol- 
lowing paroxysm. In infancy the perspiration is not abundant, and 
in the first half of this period is nearly absent. In the interval of 
the paroxysms the patient appears well, except a degree of languor. 

During the cold stage, passive congestion of the internal organs 
occurs to a greater or less extent, but the circulation is equalized 
during the reaction of the second stage. The spleen, whose cap- 
sule is distensible, soon enlarges in many patients, in consequence, 
probably, of the frequent congestions, constituting the " ague cake." 
This enlargement is more common in children than adults. Since 
my attention has been particularly directed to this subject, I have 
been able to feel the enlarged spleen, by examination through the 
abdominal walls, in about half of the cases under the age of ten 
years. The organ returns to the normal size after the ague is cured. 
From the intimate relation of the spleen to the composition of the 
blood, it is evident that the character of this fluid must be affected 
if intermittent fever be protracted. The blood becomes more and 
more impoverished, and a state of decided hydremia supervenes. 
A few weeks' continuance of the ague suffices to produce decided 
pallor of the features, and surface generally, and as all watery blood 
is prone to transudation, such patients not infrequently present 
more or less oedema of the face, ankles, and other parts. Some- 
times, also, especially under unfavorable hygienic circumstances, 
purpuric spots (purpura hemorrhagica) appear under the skin, 
affording additional proof of the change which the blood has un- 
dergone. 

Intermittent fever in children, if proper remedial measures are 
employed at an early period, is ordinarily not dangerous, and is 
quite amenable to treatment; but that comparatively infrequent 
and fatal form of it, designated the pernicious, occurs more fre- 
quently in children than adults. In ~New York city, where the 
type of malarial diseases is mild, I have never met a case of perni- 
cious intermittent in the adult, but I can recall to mind such cases 
in children, two of them fatal. This form of the fever occurs in a 
smaller proportionate number of cases in infancy than in child- 
hood, probably because the cold stage is less pronounced. In the 
pernicious ague, the system is overpowered — it does not react in a 
degree commensurate with the intensity of the disease. The patient 
enters the paroxysm, becomes stupid, and, if not relieved by prompt 
and efficient measures, enters into a fatal coma. A type of the dis- 
ease, therefore, which would not be pernicious in a robust individual, 



266 INTERMITTENT FEVER. 

may be such in one of a broken-down constitution and feeble reac- 
tive power. In most cases occurring in children the coma is pre- 
ceded by eclampsia, which is apt to be general and protracted. A 
nice discrimination would no doubt exclude from the list of the 
pernicious affection certain of those cases in which coma succeeded 
clonic convulsions, for convulsions occurring from other causes fre- 
quently end in coma, and in all probability eclampsia complicating 
intermittent fever has, in many instances, additional and distinct 
causes quite as potent as the malarial poison or state. But practi- 
cally this discrimination would subserve no useful purpose. It is 
better to consider as pernicious all those cases in which alarming 
prostration and stupor supervene in the paroxysm, requiring ener- 
getic measures to produce reaction and consciousness, whether con- 
vulsions have occurred or not. 

Protracted intermittent fever in the adult occasionally produces 
waxy degeneration of organs, and also a greater or less amount of 
pigmentary matter in the blood (melansemia). In children both 
these results are more rare. 

Treatment. — The same mode of treatment is required for chil- 
dren as for adults, namely, the employment of the alkaline prin- 
ciples of cinchona. The sulphates of quinia and cinchonia are 
most frequently prescribed. From observations made in the class 
of children's diseases in the out-door department at Bellevue, two 
grains of the sulphate of quinia seem to have about the effect of 
three grains of the sulphate of cinchonia in the treatment of ague. 
They may be given in the same manner, both requiring an acid for 
solution, but it is impossible to disguise their intense bitterness. 
The vehicle which I prefer for their administration is the syrup 
of raspberry, which, though not officinal, is easily obtained. The 
following formula is for a child of three years : — 

R. Qui. sulphat. gr. xij. 

Acid, sulphur, dilut. gtt. xviij. 
Syr. rubi. idsei §jss. Misce. 

One teaspoonful three times daily. The first dose should be ad- 
ministered immediately after the fever abates. In this climate 
two or three days suffice to cure the disease, after which one dose 
daily should be administered for a week, and then every second day 
for two or three weeks longer. 

If any difficulty is experienced in administering the medicine 
on account of its bitterness, the dragees may be employed, if the 
child is old enough to swallow them, or the tannate of quinine. 



REMITTENT FEVER. 267 

The tannate may be administered by substituting tannic acid for 
the sulphuric. One grain of tannic acid is sufficient to form a 
tannate with four grains of the sulphate of quinise. The tannate, 
however, is not as reliable as the sulphate, and it is necessary to 
administer it in a somewhat larger dose. 



CHAPTER II. 

REMITTENT FEVER. 

If a physician were to consult the standard treatises on diseases 
of children in order to ascertain the nature of remittent fever, he 
would rise from the perusal with no clear idea of it. One tells us 
that the remittent fever of children is identical with typhoid fever 
of adults ; another, that it is a gastro-intestinal inflammation ; and, 
finally, Hillier believes v that there is properly no such disease, and 
that the term should be dropped from the nosology of children. 
There is, however, a remittent fever of children as well as adults, 
and much of the confusion which exists in reference to it arises 
from the fact that writers have not kept in view what constitutes a 
fever. 

Febrile action which has a local cause is not an essential fever, 
and should not be described as such. It happens that in children 
a symptomatic remittent fever arises from a variety of local causes, 
as dentition, intestinal worms, subacute gastro-intestinal inflam- 
mation, etc. But all such cases should be excluded from our con- 
sideration of remittent fever, as clearly as we distinguish the con- 
tinued fever of pneumonia or bronchitis from that of typhus or 
typhoid. 

There is an essential remittent fever of children due to malaria. 
The same conditions which produce intermittent fever, do, in a 
certain proportion of cases, produce a fever which does not in- 
termit, but continues with more or less pronounced exacerbations 
a certain number of days, when it ceases or becomes intermittent. 
Cases, too, are not infrequent in localities not malarious, of a remit- 
tent fever, occurring more frequently in the spring and autumn 
than in other seasons. Some of these cases are perhaps a mild type 
of typhus, but in most instances the conditions do not appear to be 
present which ordinarily give rise to typhus, and they do not occur 



268 REMITTENT FEVER. 

in connection with cases of typhus in adults. The cause, though 
obscure, is apparently atmospheric. 

The symptoms of remittent fever vary in different cases. The 
exacerbations and remissions are more pronounced in some than 
others. Even in those cases in which the fever is due to paludal 
emanations, and occurs in connection with cases of the intermittent, 
the febrile movement may be almost uniform, slight exacerbations 
occurring in the latter part of the day. In other cases the exacer- 
bations and remissions are pronounced, the febrile excitement 
abating in a perspiration. Occasionally the fever is higher on each 
second day. Cephalalgia is common, and in severe cases delirium 
and stupor are not infrequent. There may be distinct remissions in 
the beginning, and afterwards, for a few days, the fever be pretty 
uniform, when it again remits or ceases. The tongue is covered 
with a light fur. Thirst, loss of appetite, a tendency to constipa- 
tion, scanty and high-colored urine, containing perhaps urates, and 
a cough due to mild bronchitis, are common symptoms. 

When remittent fever is due to marsh emanations, the same ana- 
tomical characters are doubtless present as in the adult, namely, 
blood containing more or less pigmentary matter, enlargement of 
the spleen, bronzing of the spleen, and, in severe cases, of the liver, 
and sometimes of the brain. 

The diagnosis is not always easy. On the one hand, local diseases 
with symptomatic remittent fever are to be excluded, and, on the 
other, typhus and typhoid. The discrimination of it from typhus 
and typhoid fevers is practically of little moment, but it is a mat- 
ter of vital importance to make a differential diagnosis between it 
and the local diseases. I have known one of the acutest diagnos- 
ticians and most eminent physicians of New York mistake incipi- 
ent meningitis for it, a mistake indeed not uncommon. The points 
involved in a differential diagnosis will be considered in our descrip- 
tions of the local diseases. 

Treatment. — If we have ascertained by a careful examination 
that the fever is remittent, and not symptomatic but essential, there 
is one remedy which is required in nearly all cases, namely, quinia, 
or its equivalent, cinchonia. Mild febrifuge medicines,with light 
diet, may be first employed in sthenic cases, in which the pulse is 
full and strong, and the quinia given when the fever has somewhat 
abated. The diet should be bland but nutritious, and the bowels 
be kept regularly open by citrate of magnesia or other mild ape- 
rient. Bromide of potassium or hydrate of chloral may be occa- 



TYPHOID FEVER. 269 

sionally employed as recommended in the treatment of typhoid 
fever, to produce quietude or sleep, in cases attended by delirium 
or insomnia. A warm mustard foot-hath, and cool applications to 
the head, are useful in such cases. 



CHAPTER III, 

TYPHOID FEVER. 



Typhus and typhoid fevers occur in children, but the former is 
mild and infrequent, rarely occurring except when adults of the 
same household are affected. It requires little treatment, except 
good nursing. Typhoid fever, on the other hand, is not infrequent 
in children, and, as it presents certain peculiarities prior to the age 
of puberty, it is proper to describe it in this connection. This dis- 
ease is much less frequent in infancy than in childhood, and in the 
first half of infancy is believed to be rare. Still, there can be no 
doubt that many cases in the first years of life are not diagnosticated, 
being mistaken for subacute and protracted entero-colitis. It may, 
therefore, be more common in the infant than is commonly sup- 
posed. Its period of greatest frequency in children is between the 
ages of six and twelve years. 

Causes. — It is now generally admitted that typhoid fever is 
mildly contagious, and that its specific principle abounds largely 
in the dejections and excretions of the patient. It is uncertain 
whether it is communicable by the breath of the patient, or exha- 
lations from his surface. If it is, it is slightly so, while numerous 
observations demonstrate its communicability through the use of 
night-stools or privies which contain the evacuations. There is 
little doubt also that typhoid fever originates de novo, caused by the 
miasm produced by decaying animal or vegetable matter. Nume- 
rous cases have been observed in which it originated from defective 
sewerage, or decaying vegetables in cellars, in localities in which no 
case had previously been observed. The germs of the disease may 
not only be received into the system by inspiration, but also through 
the stomach, for the use of well-water which contains the drainage 
of sewers has repeatedly been known to cause it. Boys are more 
frequently attacked than girls, according to some statistics in the 
proportion of three to one. Deterioration of the health from gene- 



270 TYPHOID FEVER. 

ral causes increases the liability to be attacked. On the other hand, 
those having tuberculosis, carcinoma, heart disease, and probably 
certain other visceral lesions, are more apt to escape than those in 
health. 

Anatomical Characters. — As typhoid fever is a constitutional 
disease, we would expect to find early and important changes in 
the blood. No alteration, however, has been discovered in this 
fluid peculiar to typhoid fever. The amount of fibrin is diminished 
as in most of the essential fevers, and its coagulation is feeble, 
forming, when the blood stands, soft, small and dark clots. "When 
the fever has continued for some time, a state of ansemia more or 
less decided supervenes, in which the amount of albumen and blood 
corpuscles is diminished. Although there are often decided symp- 
toms referable to the nervous system, no constant changes have 
been discovered in the brain or spinal cord. The changes observed 
in them when death has occurred in the course of typhoid fever 
have been for the most part due to other causes. It is different 
with the respiratory system. After the first week of typhoid fever 
bronchitis is almost as constant as inflammation of the fauces in 
scarlet fever, and accordingly we find in fatal cases redness and 
thickening of the bronchial mucous membrane, which is covered 
with a viscid and ordinarily scanty secretion. Hypostatic con- 
gestion of the lungs, with more or less oedema, and in severe and 
enfeebled cases hypostatic pneumonia, are not uncommon. In the 
bronchitis and state of feebleness we have the causes of pulmonary 
collapse, and this lesion is not infrequent over limited portions of 
the lungs, especially if the bronchitis is unusually severe. 

The lesions occurring in the digestive system are important. 
The mucous membrane of the small intestine is more or less in- 
jected, and at an early period, even by the second or third day, the 
patches of Peyer, solitary glands, and at the same time the mesen- 
teric, begin to enlarge. It has been stated by high authorities that 
the enlargement is due to infiltration with a peculiar substance, 
which has been termed the typhous material. I have made micro- 
scopic examination of these glands in typhoid fever of the adult, 
and have found a notable increase of the small round granular 
cells of which these glands are composed. I do not, therefore, 
doubt that the enlargement is due mainly to hyperplasia of the 
cellular elements of the glands, though there is probably infiltra- 
tion to a certain extent of inflammatory products between the cells. 
The mucous membrane over the glands undergoes inflammatory 
thickening and softening. In the adult, sloughing of this mem- 



SYMPTOMS. 271 

brane is frequent, with the disintegration of the glands and their 
elimination into the intestines, producing ulcers, small and circular, 
corresponding with the site of the solitary glands, large and oval 
or irregular, corresponding with the site of the agminate. Disin- 
tegration of these glands and the formation of ulcers are less fre- 
quent in children than adults. In the adult, who recovers, the 
mesenteric glands, and those of the solitary and agminate which 
are not destroyed, return to their normal state by fatty degene- 
ration, liquefaction and absorption of the redundant cells. In the 
child this is the common result, instead of sloughing and disinte- 
gration, as regards both the solitary and agminate glands, and 
uniform result as regards the mesenteric, and I may add bronchial 
glands, which are also in a state of hyperplasia. The absence of 
ulceration or its slight extent affords explanation of the fact that 
intestinal perforation is very rare in children. 

The spleen gradually enlarges, often to twice the normal size, has 
a dark red color, and is softened. Enlargement of the spleen pos- 
sesses great diagnostic value in those cases in which the diagnosis 
is obscure. For while very similar intestinal lesions may occur 
in chronic entero-colitis, the coexistence of these lesions with the 
splenic enlargement and softening shows the constitutional nature 
of the affection. 

In cases which are severe, and presenting a decidedly adynamic 
type, the muscles become soft and flabby, and the action of the 
heart is feeble, more or less passive congestion of the viscera is the 
result. In such cases congestion of the kidneys and albuminuria are 
not infrequent. 

Symptoms. — Typhoid fever has a prodromic stage of a few days, 
sometimes of a week or more, in which the child appears languid, 
indisposed to play, and has little appetite, but complains of no pain 
unless occasional slight headache, and has no symptom which would 
lead the friends or even physicians to suspect the grave nature of 
the disease which impended. By and by a slight fever occurs. 

The febrile movement, which gradually becomes more pro- 
nounced, remits, but does not cease in the morning, and has even- 
ing exacerbations. After the first week of fever the remissions are 
less marked, but the fever is not uniform at any period in its course. 
Hence some of our ablest writers on diseases of children continue 
to designate typhoid fever of children remittent fever, fully aware 
of its identity with typhoid fever of the adult. As the case advances, 
the appetite fails, all solid food being refused, and liquid food being 
taken more from thirst than hunger. The tongue in the first week 



272 TYPHOID FEVER. 

is covered with a light moist fur, and in some patients throughout 
the course of the disease, but in others having a graver type of the 
fever the tongue after the first week is dry and brown. During 
the prodromic period, and in the first week, the bowels act regu- 
larly, or are slightly relaxed, and they are readily affected by pur- 
gative medicines. After the first week there is in most children a 
tendency to diarrhoea, which requires now and then the use of 
astringents, the stools being watery and brown, or dark yellow. 
The abdominal walls are seldom retracted, but prominent, especially 
after the first week, in consequence of meteorism which is present 
in children as well as adults. Sometimes there is apparent tender- 
ness, when pressure is made over the right iliac region, but this 
must not be confounded with hyperesthesia, which is common in 
the commencement of febrile diseases in children, and which is 
observed especially upon the abdomen, chest, and inner part of the 
thighs. 

The respiration in the first week is slightly accelerated, as it is 
in all febrile diseases. In the second week, and subsequently when 
bronchitis is developed, the respiration is ordinarily more accele- 
rated, though not in a marked degree, unless in those exceptional 
instances in which there is an abundant collection of mucus in the 
smaller bronchial tubes. A cough is always present, dependent on 
the bronchitis, and varying in character according to the degree 
and stage of the inflammation. In the first days of the fever it is 
infrequent, and hacking ; at a later stage it is more frequent, and 
not so dry, though in cases of ordinary severity the amount of ex- 
pectoration is inconsiderable. Hypostatic congestion, oedema, hypo- 
static pneumonia, splenization, or thickening of the alveolar walls, 
and collapse, which may and some of which not infrequently do 
occur in the advanced disease, increase more or less the frequency 
of the respiration and the cough, and modify the physical signs. 

The pulse in the first week, in ordinary cases, is from 100 to 
110 or 115. It gradually becomes more accelerated, numbering in 
the second week 120 or more; in grave cases even 160. The more 
frequent the pulse, the greater the danger and more unfavorable 
the prognosis. During the exacerbations the number of pulsations 
per minute is 15 or 20 more than in the remissions. The change 
in temperature corresponds with that of the pulse, being from 1° 
to 2° higher in the exacerbation than remission. The extremes of 
temperature in cases of ordinary severity are about 101° and 104°. 
A temperature above 105° shows a grave, probably a malignant, 
type of the disease, or else a serious complication. 



COMPLICATIONS. 273 

There is great variation as regards the symptoms referable to the 
nervous system. Headache is common in the prodromic and initial 
stages, after which it ceases. A few are delirious even from an 
early period, screaming loudly, or muttering incoherently, but the 
majority are quiet, having, indeed, a degree of mental dulness, but 
being able to appreciate questions when aroused, and answering 
correctly. Subsultus tendinum and carphologia, which some ex- 
hibit, show that there is profound disturbance of the nervous 
system. Epistaxis occurs occasionally in the first week as in the 
adult, but is not abundant. 

The rose-colored eruption appears in children as well as adults 
between the sixth and twelfth days, but is more frequently absent 
in the former than latter, sometimes the number of spots is less 
than half a dozen. Sudamina are common in the second and third 
weeks, and perspirations may occur at any time in the course of 
the fever, but without amelioration of symptoms. More or less 
deafness is common, being in most instances a purely nervous 
symptom, without, therefore, any structural change in the ear, but 
it is possible, as has been suggested by certain writers, that it 
sometimes results from inflammatory thickening of the Eustachian 
tube or external meatus, or to a weakened and flabby state of the 
muscles of the ear. 

The duration of typhoid fever is not uniform; while mild cases 
may end in two weeks, those of a severer type continue three or 
even four, the patient becoming progressively more emaciated and 
feeble. In protracted and severe cases his condition seems very 
unpromising to one not familiar with the clinical history of the 
fever. Pale, emaciated, and feeble, probably passing his evacua- 
tions in bed, taking little notice of objects around him, he presents, 
at the close of the third week, an appearance of helplessness, not- 
withstanding the best of nursing, and the constant employment of 
sustaining measures, which is truly discouraging. 

Complications. — The chief complications of typhoid fever are 
broncho-pneumonia, already sufficiently described, enteritis, intes- 
tinal hemorrhage, peritonitis, otitis, parotiditis, and muguet. In 
one instance I lost a patient about ten years old, in whom the fever 
had nearly terminated, by the sudden accession of croup. There 
is, as we have seen, in ordinary cases, a degree of inflammation of 
the mucous membrane of the air-passages, and of the intestines 
especially in the vicinity of the patches of Peyer. It is easy to 
understand how, under circumstances which may arise in the fever 
favorable to the development of mucous inflammations, the bron- 
18 



274 TYPHOID FEVER. 

chitis and enteritis may so increase as to constitute complications. 
They are the most frequent of the serious complications. 

Intestinal hemorrhage is an occasional complication. Hillier 
met four cases in thirty of the fever. It indicates the presence of 
ulcers upon the surface of the intestines. It is one of the most 
serious of the complications. Some, in whom it has occurred, 
recover, but others die. Otitis, commencing with pain, and pro- 
ducing a discharge which may continue for weeks, is not rare, 
though less frequent than in scarlet fever. The otitis is commonly 
external, but it may, in scrofulous subjects, extend to the middle 
ear. 

Intestinal perforation is more rare in children than in adults, as 
might be inferred from the statement already made, that intestinal 
ulceration is less frequent and extensive in them. Statistics show 
that perforation occurs only once in 232 cases. Therefore, as per- 
foration is the common cause of peritonitis in this disease, this 
inflammation is a rare complication. Peritonitis may, however, 
occur in typhoid fever without perforation. In one such case (an 
adult) in the fever wards attached to Charity Hospital, local peri- 
tonitis with fibrinous exudation occurred opposite two ulcerated 
patches of Peyer, the ulcers extending nearly to the peritoneum, 
but not perforating. The lesions observed in this case throw light 
on those cases of peritonitis complicating typhoid fever which 
recover, the cause of which has received a different explanation. 

In advanced and greatly debilitated cases, thrush sometimes 
appears in the interior of the mouth, and upon the fauces. It is 
always an unfavorable prognostic symptom in children suffering 
from chronic or protracted disease. Parotiditis is also a rare com- 
plication. 

Diagnosis. — This is more difficult in children than in adults, and 
the younger the child the greater the difficulty. In infants pro- 
tracted entero-colitis, with febrile action and dry furred tongue, 
cannot in certain cases be positively diagnosticated from typhoid 
fever by the symptoms and clinical history. Typhoid fever is 
believed, however, to be rare at this age. "When, however, as now 
and then happens, a young child presents the symptoms character- 
istic of protracted subacute entero-colitis, or typhoid fever, and 
older members of the household have the fever, it is highly probable 
that the case is one of the latter disease, and it should be treated 
accordingly. 

Even in older children typhoid fever is apt to be mistaken for 
simple subacute enteritis, or entero-colitis, or vice versa. The fol- 



PROGNOSIS. 275 

lowing facts aid in the differential diagnosis. In typhoid fever 
there is total loss of appetite, while in the subacute intestinal inflam- 
mation food is not entirely refused. Diarrhoea commences early 
in the inflammation, while in the fever it is not ordinarily till after 
the lapse of a few days. The tenderness of the fever is either not 
appreciable, or it is located in the right iliac region ; in the other 
disease it is general over the abdomen, or located in the umbilical 
region. In typhoid fever there is bronchitis with a cough which 
is absent in the inflammation. In typhoid fever there are certain 
other symptoms, more or fewer of which are present in most cases, 
and which do not occur in the intestinal diseases, except as a coinci- 
dence. For example, headache, epistaxis, stupor, delirium, and 
perhaps the rose-colored spots. 

Typhoid fever may be mistaken for meningitis, during the first 
week, but in meningitis there is more constipation, irritability of 
stomach, and less elevation of temperature; moreover, in menin- 
gitis, at a comparatively early stage, we are able to detect patches 
of congestion of the features coming and disappearing suddenly ; 
slight inequality of the pupils, or their oscillation when the light is 
uniform ; signs which are lacking in typhoid fever. In a doubtful 
case the ophthalmoscope might be employed, which in meningitis 
discloses congestion of the vessels of the retina, oedema, etc., ana- 
tomical changes which do not pertain to typhoid fever. 

The differential diagnosis of typhoid fever and acute tuberculosis 
may be made by attention to the following points. In tuberculosis 
there is cough, with some acceleration of respiration from the first, 
without epistaxis, stupor, or other nervous symptoms, and without 
the abdominal symptoms which are so prominent in the fever. 

Duration. — The duration of typhoid fever varies from two to 
about four weeks, and complications which may arise greatly retard 
convalescence. Recovery from a severe and protracted attack is 
slow, several weeks or even months elapsing before complete resto- 
ration to health. A tendency to diarrhoea may continue several 
weeks after the fever proper ceases, necessitating a rigid oversight 
of the diet, and the occasional employment of astringents. 

Prognosis. — A much larger percentage of children recover than 
of adults. Although there is great emaciation with loss of strength, 
recovery may be confidently predicted, provided no serious compli- 
cation occurs. In the fatal cases which I have met, the unfavorable 
result occurred as a rule from the complications, rather than directly 
from the fever. The condition in which severe typhoid fever leaves 
a patient is favorable to the development of tubercles, and now and 



276 TYPHOID FEVER. 

then they occur, disappointing our expectations and prediction of 
recovery. 

Treatment. — As typhoid fever is self-limited, the treatment re- 
quired in ordinary cases is simple. It should be of a sustaining 
nature, both as regards diet and medicinal agents, and any untoward 
symptoms should be promptly met by appropriate measures. The 
food should be in the liquid form ; solid food is, indeed, in most 
cases, refused. Beef-tea, milk, rice or barley-water, with milk, may 
be allowed from the first. Mild cases require no stimulants, still 
the moderate use of wine is not contraindicated in such cases, and 
may be allowed at an early period. In grave cases, characterized 
by a dry and furred tongue, and quick and compressible pulse, milk- 
punch or wine-whey should be employed in suitable quantity at 
regular intervals. 

When the fever is mild and pursuing its normal course, a simple 
febrifuge may be employed, as spts. setheris nitrosi, with syrup of 
ipecacuanha. 

$. Spts. aether, nit. gij ; 

Syr. ipecac. 5"j ; 

Syr. simplic. ^jss. Misce. 
Dose, one teaspoonful every three hours to a child of six years. 

If the fever has distinct evening exacerbations, quinine is indi- 
cated as an antiperiodic, and in cases of an asthenic type, it may be 
employed in smaller doses as a tonic. In either of these conditions 
it will be found useful. In cases attended with great restlessness 
or delirium, an appropriate dose of bromide of potassium or hydrate 
of chloral at night, will procure rest, and be followed by no unfa- 
vorable result. I prefer the hydrate of chloral given in a small 
dose. A single dose of two or three grains of this agent will gene- 
rally be sufficient. For the diarrhoea, I ordinarily prescribe pare- 
goric, with half its quantity of the fluid extract of catechu in chalk 
mixture. The state of anaemia which is present in the advanced 
disease and in convalescence requires the employment of iron. The 
citrate of iron and quinine will, under such circumstances, be found 
useful. 



ACUTE RHEUMATISM. 277 



CHAPTER IV. 

ACUTE KHEUMATISM. 

Rheumatism is a constitutional disease with a local manifesta- 
tion, namely, an inflammation of the sero-fibrous tissues chiefly in 
and around the articulations, but occasionally in other parts. It 
is less frequent prior to puberty than in the years succeeding it ; 
still, it is not uncommon in children after the fifth year. Under 
this age it is comparatively rare, but is, probably, not so infrequent 
as is commonly supposed. For while in the adult the diagnosis of 
rheumatism is easy, in children this disease is likely to be over- 
looked, if, as is true in a large proportion of cases in early life, the 
swelling and redness of the affected joints are slight, and only a 
few joints are inflamed. If there is cardiac inflammation, the 
articular affection may be nearly absent, thus rendering the diag- 
nosis more obscure. That rheumatism is not so very rare under 
the age of five years, I infer from the fact that we now and then 
meet with cases of valvular disease in children of this age or older, 
which, there can be little doubt, had its origin in rheumatism, 
although the parents are not aware that there has ever been an at- 
tack of this disease. Several such cases have recently been brought 
to the children's class in the Out-door Department at Bellevue. 
Thus, in January, 1871, a little girl, three years old, was presented, 
having distinct aortic direct, and mitral regurgitant murmurs. 
The mother was not aware that she had had rheumatism, but at 
the age of twenty months she had for several days pretty active 
febrile symptoms, which the physician attributed to disease of the 
lungs. In April, 1871, another girl, of the same age, was brought 
to the clinique, having a distinct mitral regurgitant murmur. The 
mother stated that she had been well till a month previously, 
when she was confined to her bed for a few days, having a high 
fever. She was attended by a homoeopathic physician, and the 
exact character of her sickness the mother was not able to state. 
Further medical advice was sought, as the child remained delicate, 
though her health was better than at first. There can be little 
doubt that the obscure fever in this case had been rheumatic. In 



278 ACUTE RHEUMATISM. 

another child treated elsewhere, not old enough to relate the 
subjective symptoms, there was, in addition to an intense fever, 
evident pain in one foot or leg, when the limb was moved. Still, 
the nature of the disease was not diagnosticated till some time 
after recovery, when a valvular murmur was accidentally discov- 
ered. Such histories, which I do not think are rare, show, if my 
opinion of them is correct, that rheumatism may occur not very 
rarely in young children, even infants, for which purpose they are 
here introduced, but they inculcate the important practical lesson, 
that the disease at this age may be so obscure, or latent, as to be 
overlooked even by good diagnosticians. 

Some observers, meeting cases of valvular disease in children, 
without the history of rheumatism, have concluded that rheumatism 
is not the chief cause of endocarditis at this age (Dr. A. Steffen, 
Jahrbuch fur Kinder k., 1870); but the explanation which I have 
given seems to me more in consonance with the facts. Scarlet 
fever not infrequently causes endocarditis, but this exanthem is 
not apt to occur without detection, and it has been as often absent 
as has rheumatism from the histories as, given by the parents of 
young children with valvular disease, whom I have examined. 
Moreover, it is a question whether the endocarditis of scarlet fever 
is not, properly speaking, of a rheumatic origin. 

Rheumatism in children is primary or secondary. The secondary 
form occurs chiefly in the declining stage of scarlet fever and 
variola. It is stated, also, to occur occasionally in new-born infants 
during epidemics of puerperal fever. I have not observed such 
cases. 

Causes. — The important cause of rheumatism is a predisposition, 
which, in a large proportion of cases, is inherited. Hence the fact 
that it is apt to occur in different members of the same family. 
"When the family history shows a strong predisposition to rheuma- 
tism, it occurs in the child from a slight exciting cause; if no 
such predisposition exists, it only occurs through unusual circum- 
stances of exposure. The ordinary exciting cause is the same as 
in most idiopathic inflammations, namely, exposure to cold ; but a 
strong rheumatic diathesis appears to be sufficient in itself to pro- 
duce an outbreak of the disease. Children who have had one 
attack are especially liable to another. 

Symptoms. — The commencement of acute idiopathic rheumatism 
is in most cases sudden; occasionally fever, and a degree of sour- 
ness or stiffness, precede the articular affection for a few hours or 
days. The inflammation, slight at first, increases gradually, attain- 



SYMPTOMS. 279 

ing its maximum intensity within one or two days. The joint is 
painful, red, hot, and swollen. The swelling is due to inflamma- 
tory cedema of the tissues surrounding the joint and effusion 
within the joint. As in all inflammations, the vascularity of the 
parts involved is increased, the synovial membrane loses more or 
less its lustre, and the effused fluid, which is mainly serum, has 
been found, in most of the cases in which an opportunity was pre- 
sented to examine it, to contain, like the pleuritic exudation, a 
few globules of pus. Rarely, in a reduced state of the system, so 
much pus is produced within the joint as to constitute a true 
abscess, and rarely also fibrin is exuded, producing a rubbing sen- 
sation when the joint is moved, and endangering permanent adhe- 
sion of the articular surfaces. Fortunately, however, in the vast 
majority of cases, the substance exuded both without and within the 
joint is mainly serum, and therefore the rapid subsidence of the 
swelling when the inflammation ceases. The pain is commonly 
not severe when the child is quiet, but it is greatly increased if the 
joint is pressed or the limb moved. 

The joints of the extremities are most frequently the seat of 
rheumatic inflammation, but occasionally those of the trunk, as 
the intervertebral, the symphysis pubis, etc., are involved. As the 
inflammation abates in the articulations first affected it reappears 
in others, unless the materies morbi has been eliminated from the 
system. It is seldom that more than two or three of the joints are 
in a state of active inflammation at the same time. 

The temperature in acute rheumatism is elevated two or three 
degrees above that of health, and the pulse varies from 120 to 140, 
its frequency depending on the age of the patient, as well as the 
gravity of the disease. Perspiration is a common symptom. The 
appetite is impaired, the tongue slightly coated, and the bowels 
constipated. The watery element in the urine is diminished, as in 
most febrile diseases. There is no corresponding reduction in the 
solid elements, so that the urine is rendered more dense, and its 
specific gravity is high. The amount of urea and coloring matter 
excreted from the kidneys is augmented during the active period 
of rheumatism, and the urine, when it cools, deposits urates. In 
ordinary cases there is no prominent symptom referable to the 
nervous system, with the exception of the pain in the affected joint. 

Acute rheumatism, if only the articulations were involved, 
would be a disease of little danger, however painful, but unfortu- 
nately, in its proneness to produce specific inflammation of the 
sero-fibrous tissues, the heart frequently becomes involved, less 



280 ACUTE RHEUMATISM. 

frequently the lungs and pleura, and in rare instances the cerebra* 
or spinal meninges. Endocarditis is the most frequent of the heart 
inflammations occurring in rheumatism ; pericarditis, though less 
common, is not infrequent, while in rare instances myocarditis 
occurs, usually associated with the other inflammations. Endo- 
carditis is limited to the left side of the heart, and seldom continues 
long without engaging the valves, aortic or mitral, or both, causing 
their infiltration, fibroid degeneration, with consequent thickening, 
and sometimes adhesion. The valvular lesion thus produced is 
in most instances permanent, so impairing the action of the valves 
as to obstruct in greater or less degree the flow of blood through 
the orifice or allow its regurgitation. 

The mitral valve is more frequently affected than the aortic, at 
least bruits produced by this lesion are more frequent in the mitral 
than aortic orifice, and when they are heard in both orifices they 
are commonly loudest in the mitral. This fact, noticed by different 
observers, I have repeatedly verified by observations in this city. 

While the articular affection pertains to the clinical history of 
rheumatism, the internal inflammation, whether of the heart, lungs, 
pleura, or meninges, though similar as regards its pathological cha- 
racter, is properly regarded as a complication. Acute rheumatism 
is so frequently complicated by one or the other of these affections, 
that any disproportionate severity in the general symptoms, as 
compared with the inflammation of the joints, or any sudden and 
unexpected increase in the symptoms, should always lead the 
physician to examine thoroughly the condition of those organs 
which are most frequently affected. 

Inflammatory complications occur, as a rule, during the active 
period of rheumatism, when the inflammation is passing from 
joint to joint. If the general symptoms begin to improve, and no 
new joints are involved, the liability to complications is greatly 
diminished. Secondary rheumatism, occurring in most instances 
in connection with certain eruptive fevers, especially scarlatina^ 
commonly affects only a few joints, often only one or two, as the 
wrist, and, though painful, is attended by slight swelling and 
redness. 

Duration, Prognosis. — With proper treatment and without 
complication the febrile action in a few days begins to abate, and 
the disease commonly terminates within two weeks. Its duration 
is ordinarily shorter than in rheumatism of the adult. Fluctua- 
tions, however, are liable to occur. The disease may appear to be 
abating, and the articular inflammations nearly cease, when they 



DIAGNOSIS. 



281 



return for a time, often without new exposure and without appre- 
ciable cause. The prognosis, even when cardiac inflammation has 
supervened, is in most cases favorable, except so far as the lesion 
resulting from this inflammation is concerned, which being perma- 
nent may entail much subsequent suffering, and occasion death 
after months or years. Indeed, what is most to be dreaded in cases 
of acute rheumatism is valvular disease or pericardial adhesion with 
its remoter consequences, namely, hypertrophy of heart, congestion 
and oedema of the lungs, dropsies, etc. 

Secondary rheumatism occurring in scarlet fever is sometimes 
also complicated with, or rather coexists with, cardiac inflammation, 
pleuritis, or pneumonitis, rendering the prognosis more unfavorable. 

In rare instances the acute symptoms of rheumatism abate, but 
the joints remain stiff and more or less swollen, and painful when 
moved. The acute has lapsed into a subacute or 
chronic rheumatism. Such a case, represented 
in the accompanying figure, was brought to 
the children's class in the Out-door Depart- 
ment at Bellevue Hospital, in February 1871. 
E. H., female, 3 J years old, had intermittent 
fever from the age of nine to fifteen months. 
From this time she remained well till the age 
of two years, when she was taken with acute 
rheumatism, commencing in her ankles and 
extending to other joints. The knee and hip 
joints on both sides have only partially re- 
covered their mobility, and both legs and both 
thighs are permanently flexed, so that the gait 
is slow and unsteady. It is impossible to 
straighten either limb without causing great 
pain, and attempts to straighten the thigh 
produce the arch in the back very similar to 
that in coxalgia. 

Diagnosis. — This is not difficult in ordinary cases, if a proper 
examination is made. In the commencement, if the affection of 
the joints is slight, rheumatism might be mistaken for remittent, 
typhoid, one of the eruptive fevers, or meningitis ; but, on careful 
examination, tenderness will be observed of one or more of the 
articulations, and probably some swelling. This tenderness is 
readily distinguished from the hyperesthesia which is common in 
the first stage of the essential fevers, and which is observed when 
pressure is made upon the chest or abdomen as well as upon the 




282 ACUTE RHEUMATISM. 

limbs, and is more marked between the joints than in them. Any 
doubt which may at first exist, whether the patient may not have 
one of those diseases, is soon dispelled, since their clinical history 
presents notable differences from that of rheumatism. 

I have known scrofulous arthritis, or scrofulous ostitis near the 
joint, present so close a resemblance to acute rheumatism as to 
be at first mistaken for it. In one instance this inflammation 
commenced in three distinct points, so that the differential diag- 
nosis at first was difficult. But scrofulous inflammation as well as 
that from pyaemia can be diagnosticated from rheumatic disease of 
the joints, by its greater persistence, less induration and symmetry 
in the swelling, and by the history of the case. Chronic rheuma- 
tism may produce deformity similar to that from chronic scrofulous 
inflammation, as in the case detailed above, but the rheumatic 
history, number of joints affected, bilateral character of the in- 
flammation, good general health, etc., are sufficient to establish a 
clear diagnosis. 

Treatment. — The theory of the pathology of a disease deter- 
mines the mode of treatment.. It is believed that rheumatism is 
due to an acid, probably lactic, in the blood, and hence alkaline 
remedies are commonly employed, with the apparent effect of 
diminishing the severity of the disease and shortening its dura- 
tion. The tartrate of soda and potassa, acetate of potassa, and the 
bicarbonate of soda or potassa, may be given singly or combined, 
according to the condition of the patient. The following is a good 
formula for a previously healthy child of six or eight years : — 

R. Potas. et sodse tart, ^ss ; 
Potas. acetat. 5ij ; 
Syr. limonum, 
Aquae, aa §iij. Misce. 
Dose, two teaspoonfuls every two or three hours. 

Sulphate of morphia, Dover's powder, or other opiate, is ordina- 
rily required in the evening to procure rest and prevent any undue 
purgative effect of the medicine. If there is considerable pain in 
the joints, one or two doses of the same should be given through 
the day. If there is a tendency to diarrhoea, or a state of debility, 
measures of a more sustaining nature are required. For such 
cases the bicarbonate of soda or potassa is preferable to the other 
alkalies. 

In a few days, by the alkaline treatment, the urates cease to 
appear in the urine, and the disease begins to decline. There is 
now little danger that any complication will occur if the internal 



TREATMENT. 283 

organs have so far escaped. I know no remedies so effectual in 
relieving not only rheumatic inflammations of the joints, but the 
general muscular tenderness which occurs from taking cold, and 
which is often present in the commencement of rheumatism, as 
the Rochelle salts and acetate of potash. 

During the declining period of rheumatism and in convalescence, 
quinine or some preparation of cinchona should be employed, and 
the alkali given less frequently. This tonic does indeed appear to 
exert a beneficial effect on the course of rheumatism, and it is 
employed by some judicious and experienced physicians from the 
commencement, as the main remedy. Certainly, in all cases of 
debility, it, or a similar medicine, should be early employed, unless 
contraindicated by some complication. 

Rheumatism impoverishes the blood, and the patient often begins 
to present an anaemic appearance, when he requires iron in addi- 
tion to the vegetable tonic. The citrate of iron and quinine may 
then be employed. 

Secondary rheumatism requires sustaining treatment from the 
first. Cases occurring in my practice have done well without 
alkalies, and with the general supporting measures employed for 
the primary disease. 

Pneumonitis complicating rheumatism is best treated by mode- 
rate counter-irritation and emollient poultices, and the internal use 
of carbonate of ammonia; or, if there is anaemia, carbonate of 
ammonia with citrate of iron and ammonia. The other internal 
inflammations which are liable to arise as complications require 
iodide of potassium in decided doses. In pericarditis or endo- 
carditis, if, as is commonly the case, the movements of the heart 
are accelerated, the tincture of aconite root, or, in young and 
debilitated children, tincture of digitalis, is required to the extent 
of reducing the number of pulsations to near the normal fre- 
quency. A child of six years can take one drop of aconite, or 
three or four times the quantity of digitalis, to be repeated, if 
necessary, in three hours, till the required reduction of the pulse is 
effected. Patients often express the relief from the palpitation and 
dyspnoea which they experience by the use of these agents. 

The patient should be kept quiet, in a room of uniform tempera- 
ture, and not exposed to draughts of air. By such precaution the 
danger of complications is greatly diminished. Repellent applica- 
tions, as cold or irritants, should not be applied to the joints, as 
long as the disease is acute, for they also increase the danger of 
complications. The affected joints should be enveloped in flannel 
or cotton, and the pain, if intense, may be diminished by applying 



284 



ERYSIPELAS 



flannel wrung out of warm water. If the disease becomes sub- 
acute or chronic, if the urates have disappeared from the urine, 
and the inflammation ceases to pass from joint to joint, the tinc- 
ture of iodine, or moderately stimulating embrocations, applied to 
the joints, involve no danger and are useful. 



CHAPTER V. 

ERYSIPELAS. 



The term erysipelas is applied to a constitutional or blood dis- 
ease, which is characterized by inflammation of the skin and 
subcutaneous cellular tissue, and by a tendency to spread. It is 
accompanied by a burning and pricking sensation, swelling, and 
subcutaneous infiltration. 

In rare instances, in young infants, an inflammation which has 
been designated erysipelas occurs in and around the umbilicus. It 
commences about the time of the detachment of the umbilical 
cord, and is accompanied by redness of the skin, tumefaction, and 
hardness of the cellular tissue surrounding the umbilicus. It 
usually causes ulceration of the umbilical fossa, and, in fatal cases, 
pus is sometimes found in the umbilical vessels. This disease does 
not show any tendency to spread ; the diameter of the inflamed 
surface is not more than three or four inches, with the umbilicus 
at the centre. It is generally fatal ; but two favorable cases have 
been reported to me, in one of which there was considerable ulcera- 
tion, and after recovery a firm cicatrix occupied the site of the 
umbilicus. The most reasonable view is that this disease is pri- 
marily an inflammation of the umbilical fossa and vessels, induced 
by uncleanliness, cachexia, or other cause. It lacks the distin- 
guishing feature of erysipelatous inflammations, namely, the ten- 
dency to spread, and I shall therefore take no further notice of it 
in this connection. (See Diseases of the Umbilicus.) 

Erysipelas seldom occurs in childhood ; the few cases which are 
met in this period present nearly the same features, and pursue 
nearly the same course, as in the adult. In infancy, on the other 
hand, erysipelas is not a rare disease. Every practitioner is called 
to cases, from time to time. The following remarks relate to ery- 
sipelas occurring in this period of life. My views have been 
derived mainly from the records of cases which occurred in this 
city, some in my own practice, but most in the practice of other 



ERYSIPELAS 



285 



physicians. The points of chief interest in forty-one cases are 
embraced in the following table : — 

Cases of Infantile Erysipelas. 



6 


X 


Age. 


Point of 


Parts affected. 


Duration. 


Result. 


HI 




sommencement. 








l 


M. 


5 months 


Right knee 


Entire surface, except face and scalp 


5 weeks and 
3 days 
7 days 


Recovered. 


2 


M. 


2 years 


Left knee 


From a little above the knee to the ankle 


Recovered. 


3 


M. 


10 months 


Elbow 


Whole arm and forearm 




Recovered. 


4 


F. 


1 year & 
8 months 


Below right 
knee 


Entire leg, thigh, and trunk to the um- 
bilicus 


7 days 


Recovered. 


5 


F. 


9 months 


Vnlva 


Abdomen, chest, and all the extremities 


18 days 


Recovered. 


6 


M. 


9 days 


Genitals 


Both lower extremities, abdomen to the 
umbilicus 


6 days 


Died. 


7 


F. 


1 year 


Vnlva 


Entire surface, except face 


6 weeks 


Recovered. 


8 


F. 


6 weeks 


At or near the 
ear 


Forehead and side of face 


1 week 


Died in 
tetanic 


9 




9 months 


Epigastric re- 
gion 


Trunk and lower extremities 


2 weeks 


spasms. 
Died in 
tetanic 
spasms. 


10 


F. 


10 months 


At angle of 
mouth 


Entire face and scalp 


10 days 


Recovered. 


11 


F. 


4 weeks 


Vulva 


Entire surface, except face 


3 weeks 


Died. 


12 


F. 


3 months 


Vulva 


Surface of abdomen to umbilicus and 
right lower extremity 


2 weeks 


Recovered. 


13 


F. 


4 to5mos. 


Vulva 


All the limbs and the trunk, except the 
chest 


3 to 4 weeks 


Died. 


14 


F. 


5 months 


From syphilitic 
sores around 
anus 


Trunk and both lower extremities 






15 


F. 


3 months 


Vulva 


Entire trunk and both upper extremities 


3 weeks 


Recovered. 


16 


M. 


8 months 


Face near nos- 
trils 


Entire trunk and both upper extremities 


About 2 
weeks 


Recovered. 


17 


F. 


4 months 


Vulva 


Entire trunk and all the extremities 


1 week 


Died. 


IS 


F. 


7 months 


Knee 


A portion of trunk and both lower ex- 
tremities 


3 weeks 


Recovered. 


19 


F. 


6 months 


Near the ear 


Entire face and forehead 


10 days 


Recovered. 


20 


M. 


7 days 


Left eyelid 


Left side of face 


3 days 


Died. 


21 


M. 


14 days 


Genitals 


Extended to knees, over abdomen to the 
chest 


4 days 


Died. 


22 


M. 


3 months 


Under the chin 


Chin, left cheek, neck, left side of trunk, 
left thigh, and leg 






23 


F. 


2 years & 
4 months 


Right shoulder 


Arm and forearm 


1 day 


Died in con- 
vulsions. 


24 


F. 


3 or 4 days 


Vulva 


Body and all the limbs 


12 days 


Died. 


2.5 


F. 


3£ months 


Under left ear 


Neck, chest, and arms 


About 2 
weeks 


Died. 


26 




7 months 


Below right 
knee 


Trunk, neck, and head, and all the limbs 


2 weeks 


Died coma- 
tose. 


27 


F. 


6 months 


Vulva 


Both thighs, and nearly entire trunk 


3 days 


Died coma- 


2S 


M. 


19 months 


Near point of 
vaccination 


Shoulder, arm, and forearm 


21 days 


tose. 
Recovered. 


29 


M. 


4 months 


Near point of 
vaccination 


Chest, and both upper limbs 


2 weeks 


Recovered. 


30 


F. 


2 months 


Near vaccine 
vesicle 


Trnnk, and all the limbs 


10 days 


Died. 


31 




3to4mos. 


Near vaccine 
vesicle 


Arm, forearm, and shoulder on one side 


2 to 3 weeks 


Died. 


32 


F. 


4 months 


Near vaccine 
vesicle 


Arm, forearm, and trunk 


2 months 


Died. 


33 


M. 


2 months 


Near vaccine 
vesicle 


Nearly entire surface 


1 week 


Died with 
peritonitis. 


31 


M. 


5£ months 


Near point of 
vaccination 


Arm and forearm 




Recovered. 


35 


M. 


2£ months 


Near point of 
vaccination 


Arm 


7 days 


Died prob- 
ably of 


3c 


M. 


8 months 


Near vaccine 

vesicle 
Left foot 


Arm and forearm 


17 days 


peritonitis. 
Died. 


37 




5 months 


Leg, thigh, and lower part of trunk 


2 weeks 


Died with 














pneumo- 


35 




5 weeks 


At one ear 


Entire surface 


2 weeks 


nitis. 
Recovered 


& 




2 months 


Left leg 


Trunk, and all the limbs 


2 weeks 


Recovered. 


41 


k .. 


4 months 


Near point of 
vaccination 


Trunk, and all the limbs 


2 weeks 


Died. 


4] 


M. 


14 months 


Face 


Trunk, and all the limbs 


4 weeks 


Recovered. 



286 EEYSIPELAS. 

Age. — Of the above cases, 27 were under the age of six months ; 
9 from six months to twelve, and only 5 above the latter age. A 
large majority, therefore, of cases of infantile erysipelas occur in 
the first year of life. 

Point of Commencement. — In 58 cases in which I have ascer- 
tained the point of commencement, it was in 13 cases the vulva, 17 
the arm after vaccination, 7 the leg, 6 the face, 3 the male genital 
organs, 3 at or near the ear, 1 the elbow, 1 the shoulder, 1 the 
nates, 1 the foot. In the adult, idiopathic erysipelas commonly 
commences upon the face, and affects only the face, ears, forehead 
and scalp. On the other hand, in infantile erysipelas, statistics 
show that the rash commences upon the face only in a small pro- 
portion of cases, one in nine, and that it rarely extends to the face 
when it commences in other parts. 

Causes. — In erysipelas the first departure from the healthy state 
occurs in the blood, or the system generally. This undergoes cer- 
tain changes which predispose to erysipelas, or are sufficient in 
themselves to give rise to it. Among the causes which produce 
this state of system, uncleanliness, residence in damp, dark, and 
crowded apartments, and defective alimentation, hold a principal 
place. Hence this disease is more common in the poor quarters 
of the city than in the country, and in dispensary and hospital 
than in civil practice. 

In a large proportion of cases there is a local exciting cause of 
the erysipelatous eruption, namely, an irritation or inflammation 
at some point, generally trivial, but which is sufficient to develop 
the disease in the system already prepared for it. It is very apt to 
commence at or near a simple ecthymatous or impetiginous erup- 
tion, around burns or suppurating sores or syphilitic eruptions ; it 
frequently commences, as is seen by the above table, near the point 
of vaccination immediately after vaccination, or when the pock is 
developed, or again when it has run its course and been detached. 
In a considerable proportion of cases it commences at a point where 
the skin is thin and delicate, or where it unites with a mucous 
surface, probably from some uncleanliness or irritation of those 
parts. Thus, I have records of cases in which it commenced at 
the external ear, commissure of the mouth, and at the vulva. In- 
deed, the frequency with which it commences at the vulva renders 
female infants more liable to it than males. In some instances 
erysipelas begins without any local exciting causes, upon smooth 
and sound skin, even when there are sores upon various parts of 
the surface. 



causes. 287 

Vaccination, as an exciting cause of erysipelas, demands particu- 
lar notice. Often, doubtless, it is the inflammation, which neces- 
sarily arises from the cut or the vesicle, which operates as an 
exciting cause of the erysipelatous affection, and not any delete- 
rious property contained in the virus which is employed, so that 
an equal degree of inflammation occurring in any other way, as 
from a burn, would be attended by a like result. But facts show 
that the virus itself occasionally contains a latent noxious prin- 
ciple, which, introduced into the system, operates as a cause of 
erysipelas. Thus, a little girl was vaccinated by me in November, 
1860, and about the time when the vesicle began to fill she was 
seized with severe inflammation of the fauces, attended by tume- 
faction and infiltration of the submucous connective tissue. The 
inflammation rapidly subsided, and within a week from its com- 
mencement the throat affection had nearly or quite disappeared. 
I now believe that the disease of the fauces was erysipelatous, 
although it was not suspected at the time to have this character. 

As the girl was otherwise healthy, and the vaccine vesicle passed 
through its usual stages, and presented the usual appearance, the 
scab was employed six weeks afterwards to vaccinate two infants. 
Within twenty-four hours after vaccination both these infants were 
seized with high fever, ushering in severe erysipelas, commencing in 
one around the point of vaccination, and in the other around syphi- 
litic sores near the anus. In the former case the erysipelatous rash 
extended from the shoulder over the entire limb, and was obstinate, 
twice reappearing, and extending over the same surface ; in the 
latter (a mulatto child) it extended over both lower extremities 
and a considerable part of the trunk, when the case passed into the 
hands of another physician, and the result is not known. The 
instrument with which the vaccinations were performed was clean. 
The vaccine disease did not appear in either of these cases. 

Again, a well-known physician of this city vaccinated three 
infants, one his own (No. 32 of the table), with part of a scab 
which had been pronounced good, but was taken from a child that 
he had not seen, and with whose state he was not familiar. These 
infants were all affected with erysipelas from the vaccination, his 
own dying. He had taken the precaution to rub the lancet on his 
boot before using it. Another physician of this city has informed 
me that he vaccinated two children in the same family with a 
scab, with all the precautions that he had ever used, and both were 
soon after affected with erysipelas of a severe form, extending 
from the point of vaccination ; the vaccine disease did not appear. 



288 ERYSIPELAS. 

I know of no case in which the vaccine lymph gave rise to ery- 
sipelas, and, probably, it rarely or never does. In the lymph there 
is no admixture of foreign substances, whereas in the scab there 
is a large proportion of animal matter. 

There is a form of erysipelas which occurs in the infant imme- 
diately after birth, and which is sometimes met in private prac- 
tice, but is most frequently observed as an epidemic in lying-in 
wards. It is associated with severe, and commonly fatal, puer- 
peral fever (metro-peritonitis), or erysipelas of the mother. This 
form of erysipelas is fatal, almost without exception, and its con- 
tagiousness is generally admitted by those who have had an oppor- 
tunity to observe cases. 

A case showing this relation of erysipelas in the newly-born 
infant to disease of the mother occurred in the practice of Dr. 
Learning, of this city. A woman gave birth to a healthy infant, 
on the 27th of July, 1860. A few days subsequently she was seized 
with a chill, followed by erysipelas, commencing on the thighs, and 
terminating fatally August 17th. As no autopsy was allowed, the 
state of the internal organs was not ascertained. A few days be- 
fore her death the same disease commenced on the infant. It ex- 
tended around the neck, upon the ears, down the arms, and termi- 
nated fatally August 24th. But erysipelas in the new-born infant 
occurring in connection with erysipelas in the mother, is more rare 
than its occurrence with puerperal fever. The records of lying-in 
asylums furnish many examples of epidemics of puerperal fever, in 
which the infants of affected mothers perish of erysipelas. 

The late Dr. Folsom, of this city, furnished me the following 
sketch of cases which occurred in his practice and that of his 
partner : "About the year 1840, being then in practice in New 
Bedford, Mass., I was called to visit a man who complained of 
pain in the knee. The next morning he was easier, but the fol- 
lowing evening his symptoms grew worse, and as I was engaged 
in a case of obstetrics, my partner, Dr. E. C, now dead, visited 
him. At my call, next morning, I unexpectedly found the patient 
dying. The disease was obscure, and at the autopsy next day no 
lesion was discovered. In making the examination, Dr. C. pricked 
his finger, and experiencing little inconvenience from it at first, 
he attended a case of confinement on the following morning. A 
few hours subsequently he was taken sick, and I took charge of 
the lady, who died in three days, having the tumid abdomen and 
symptoms of childbed fever. The infant of the patient was seized, 



PREMONITORY SYMPTOMS. 289 

when two days old, with erysipelas, appearing on the face and in 
spots on the trunk and limbs, and terminating fatally in one day. 
Dr. C.'s finger became swollen and painful, and the lymphatics of 
the forearm and arm became inflamed, presenting red lines, and 
the axillary glands suppurated. Though feverish and much pros- 
trated, there was no appearance of erysipelas in his case. In about 
two weeks he resumed practice, and as at that time physicians in 
this country were not fully aware of the danger of communicating 
puerperal fever, he attended two, three, or four obstetrical cases 
each week, until the number reached fifteen. All the mothers 
died with symptoms of metro-peritonitis, and all the infants had 
erysipelas, commencing on the face or some part of the body, 
generally on the second or third day after birth, and in all termi- 
nating fatally within a week. This sad record was finally ended 
by the doctor's temporarily retiring from practice." 

Dr. Condie, in his Treatise on Diseases of Children, says : " Ery- 
sipelas of infants very commonly occurs during the prevalence of 
epidemic puerperal fever. Children of mothers who become af- 
fected with the fever are often born with erysipelatous inflamma- 
tion ; others are attacked almost immediately after birth. Whether, 
in these cases, the disease is to be referred to a morbid matter ap- 
plied to the skin in the womb, or to the same epidemic or endemic 
influence which gives rise to the disease of the parent, it is diffi- 
cult to say. According to M. Trousseau, infantile erysipelas is 
principally observed when puerperal fever prevails in the wards of 
the lying-in hospitals at Paris." In private practice it is rare that 
we meet erysipelas of the iufant associated with erysipelas or with 
puerperal fever in the mother. Some of the oldest physicians of 
this city, with whom I have conversed, and who are engaged in 
extensive general practice, state that they have never met a case 
in which there was this relation. Cases like those observed by Drs. 
Folsom and Learning only occur when epidemic erysipelas or puer- 
peral fever is prevailing. 

Premonitory Symptoms. — Infantile erysipelas in certain cases has 
no premonitory stage, or, if present, it escapes notice. In other in- 
stances there are well-marked precursory symptoms, as drowsiness, 
or restlessness, febrile movement, oppressed respiration, with per- 
haps vomiting, and starting or twitching of the limbs. In Cases 
28 and 37 of the table, which occurred in my practice, the febrile 
movement, restlessness, and oppressed respiration were so great for 
three days before the appearance of the eruption, as to cause much 
anxiety. In the adult, pharyngitis often precedes the occurrence 
19 



290 EEYSIPELAS. 

of the rash upon the skin. The same inflammation may be present 
in the premonitory period of infantile erysipelas, as well as during 
the period of erysipelatous eruption. The hurried and difficult 
respiration, which is present in the commencement of some cases, 
is probably due to an erysipelatous turgescence of the bronchial 
mucous membrane. 

Symptoms. — The patient with this disease is usually restless, in 
consequence of the burning pain which accompanies the eruption. 
In severe cases there is little sleep, night or day, except from medi- 
cine. The sleep is short, and is often interrupted by sudden start- 
ing, or twitching of the limbs. Convulsions may occur, but are not 
common. 

Febrile movement is constant, and is proportionate to the extent 
and gravity of the erysipelas. I have notes of cases in which the 
pulse was more than 200 per minute, although other symptoms 
did not indicate immediate danger. The skin not affected by ery- 
sipelas is dry and hot, though not possessing the pungent heat of 
the inflamed portion ; face often flushed ; tongue moist, and covered 
with a light fur; stomach usually retentive. The state of the 
bowels varies ; sometimes they are regular, sometimes variable, 
while in other cases the stools are green, and more frequent than 
natural. I have records relating to the state of the bowels in 
twenty cases, as follows : in seven, regular ; in nine, loose ; in two, 
constipated ; in one, constipated, then loose ; and in one, consti- 
pated, then regular. Diarrhoea, when present, is usually mild, 
requiring little or no treatment. The erysipelatous redness is not 
in all cases so pronounced as in the adult, but otherwise there is 
nothing peculiar in its appearance. In feeble infants, with an im- 
poverished state of the blood, its color is pink, instead of the deep 
red which characterizes the inflammation in the robust. Points 
of vesication may occur where the inflammation is most severe, as 
in the adult, and subsequently the same desquamation and oedema. 

If the infant is debilitated, there is great danger of the forma- 
tion of abscesses, around which the inflammation lingers after it 
has disappeared from every other part of the body. Sometimes 
also, in very young infants, gangrene occurs, especially of the geni- 
tal organs in the male. Several of these cases have been related to 
me, all under the age of a month or six weeks, and all fatal. Oc- 
casionally the sloughing is so great as to denude the testicles. A 
noteworthy feature of erysipelas in infants is its proneness to 
return. When it has been progressively subsiding, and hope is 
entertained of its speedy disappearance, it not infrequently is sud- 



PROGNOSIS — DURATION". 291 

denly relighted from some unknown cause, travelling again over the 
same, or parts of the same, surface. In one case the disease, arising 
from vaccination, extended three times over the arm and forearm ; 
and in another case, a second time over both legs and a considerable 
part of the trunk. 

The internal inflammations, which most frequently complicate 
erysipelas, and give rise to symptoms which are superadded to those 
pertaining to the erysipelas, are pharyngitis and peritonitis ; and 
more rarely broncho-pneumonia or enteritis. In a case which I ex- 
amined after death, in the Nursery and Child's Hospital, and in 
which the erysipelatous inflammation having extended over the 
abdomen, the lesions of peritonitis were present, it seemed probable, 
from the thinness of the abdominal walls, that the inflammation 
had extended through the parietes from the external to the internal 
surface. 

Prognosis. — Erysipelas is much more fatal in infancy than in 
adult life. In the death statistics of this city for three years, I 
find eighty deaths from erysipelas of infants under the age of one 
year, to eighty-three deaths from this disease above that age. Age 
greatly influences the prognosis. Infants under the age of three 
weeks usually die ; from the age of three weeks to six months the 
result is doubtful ; while above the age of six months a majority 
recover with correct treatment. It will be seen by the foregoing 
table that seven infants under the age of six weeks had erysipelas, 
and six died ; from the age of six weeks to six months, six recov- 
ered and nine died ; and above the age of six months, nine recovered 
and four died. 

With the exception of a case of the so-called umbilical erysipe- 
las, the youngest child who recovered, of whom I have obtained 
information, was three weeks old. In this case the rash extended 
nearly over the entire surface, beginning with the face. Case 38 
of the table, treated by myself, was very similar as regards the 
extent of the erysipelatous eruption and the result. This infant 
was Hve weeks old. 

It is scarcely necessary to state that erysipelas is more favorable 
when it affects the limbs than when it invades the head, neck, or 
body ; when it spreads slowly than rapidly ; when it is superficial 
than when phlegmonous. In those cases in which the connective 
tissue is much involved, the infant is not always safe after the 
disease has run its course ; he sometimes dies exhausted from the 
discharge of abscesses : I have records of two such cases. 

Duration. — In sixteen cases that recovered, the disease termi- 



292 ERYSIPELAS. 

nated within the first week in two, the second week in six, the 
third week in five, fourth week in one, and in two cases it lasted five 
and six weeks. The average duration was fifteen days. In nine- 
teen fatal cases, ten died within the first week, five the second 
week, three the third week, and one in the fourth week. The 
average duration of fatal cases was ahout ten days. 

Modes op Death. — Death occurs in different ways ; in clonic or 
tonic convulsions followed by coma, from exhaustion, and from 
internal inflammation, that from exhaustion being probably the 
most common. 

Pathological Anatomy. — The blood doubtless in this disease 
undergoes certain pathological alterations previously to the oc- 
currence of the eruption, but the exact changes are not known. 
Our knowledge of the morbid anatomy of erysipelas relates chiefly 
to the local affections, which, with the exception of the inflamma- 
tion of the skin, are not constant, and may, therefore, be regarded 
as complications. The cutaneous inflammation affects all the 
structures of the skin, and in greater or less degree also the sub- 
cutaneous connective tissue. The inflammation is accompanied by 
more or less serous effusion or oedema. 

The not infrequent occurrence of peritonitis in connection with 
erysipelas has long been known. In Heberclen's Epitome Morbo- 
rum Pueriliiim, the anatomical character of erysipelas is expressed 
in one sentence: "When the body has been opened after death, 
the intestines have been found glued together and covered with 
coagulable lymph." Since Heberden's time, nearly all who have 
written on diseases of infancy and childhood have mentioned 
peritonitis as one of the most common complications. Under- 
wood says : " Upon examining several bodies after death, the con- 
tents of the body have frequently been found glued together and 
their surface covered with inflammatory exudation, exactly similar 
to that of women who have died of puerperal fever." Similar 
remarks in reference to the frequency of peritonitis in this disease 
are made by recent writers. 

The statistics in reference to this disease appear to demonstrate 
that in infants in hospital practice, and in those affected by ery- 
sipelas during epidemics of puerperal fever, peritonitis is a not 
infrequent complication. On the other hand, as we commonly 
meet cases of infantile erysipelas occurring sporadically in private 
practice, there is not sufficient abdominal distension and tender- 
ness for peritoneal inflammation. In only one of the cases em- 
braced in the foregoing table was a post-mortem examination 



TREATMENT. 293 

made, and in that there had been no peritonitis. The occurrence 
of pharyngitis in connection with erysipelas has been already al- 
luded to. 

Enteritis has been alluded to as another complication in infants. 
Diarrhoea has been stated to be a symptom in certain cases ; it has 
been found to be dependent on enteritis of a mild grade. Billard 
made post-mortem examinations of sixteen cases of infants dying 
of erysipelas, and "found in two gastro-enteritis, in ten enteritis, 
in three pneumonia complicated with enteritis and cerebral con- 
gestion, and in one pleuro-pneumonia." 

Treatment. — On this side of the Atlantic great uniformity pre- 
vails as regards the treatment of erysipelas. Sustaining measures 
are prescribed, and the tincture of the chloride of iron is the tonic 
generally preferred. "Whatever the intensity of the febrile reac- 
tion and the stage of the disease, if there is no intestinal compli- 
cation, ferruginous or other tonics should be administered. The 
largest doses of the tincture of the chloride of iron given in any of 
the cases in the above table were in case 'No: 4, namely, ten drops 
every two hours, and this patient recovered in seven days from a 
pretty severe attack. Probably, however, nothing is gained by 
such large doses, and they may irritate the intestinal surface, and 
increase the liability to enteritis, which, we have seen, complicates 
a certain proportion of cases. Two drops may be given every three 
hours to a child from one to two years of age. Instead of the 
iron, or in addition to it, one of the preparations of cinchona may 
be prescribed. Beef-tea, and in most cases wine-whey or other 
alcoholic stimulant, are required. 

The depressing measures recommended by certain writers cannot 
be too strongly censured. Bouchut says : " We should endeavor 
from the first to allay the inflammation of the skin by energetic 
treatment. . . . Local abstraction of blood, by means of one 
or two leeches applied at the circumference of the primary seat of 
the erysipelas, should be put in force, provided the power of the 
constitution of the children permits." Such treatment may ex- 
plain one of Bouchut's aphorisms, namely, the erysipelas of infants 
is a fatal disease. 

Local treatment may be employed to arrest the extension of the 
inflammation, but the result in most cases is not encouraa'ino;. 
Solid nitrate of silver was employed in two cases, of which I have 
records, and in both the result was pernicious. Troublesome sores 
were produced, from which blood escaped, and in one of the cases, 



294 ERYSIPELAS. 

at least, death was attributed by the parents to this treatment, 
rather than to the disease. 

Tincture of iodine is a better remedy for arresting the exten- 
sion of erysipelas. It should be applied from the margin of the 
inflammation, over the sound skin, to the distance of about two 
inches. It may be ineffectual, but it does not produce any unfa- 
vorable result. Soothing applications, like rye flour, or a lotion of 
sugar of lead, may be made to the inflamed surface, as in erysipe- 
las of the adult. I prefer, however, for local treatment, the con- 
stant application of glycerine, or glycerine and water, to which a 
few drops of carbolic acid are added. 



PART III. 



SECTION I. 

DISEASES OF THE CEREBRO-SPINAL SYSTEM. 

Diseases of the brain and spinal cord are less frequent than 
those of the respiratory and digestive systems. They are also less 
amenable to treatment, and are much more fatal. They largely 
increase the aggregate of deaths. They contrast with the diseases 
of the other systems in their greater relative frequency in infancy 
and childhood than in adult life. This is explained, as regards the 
brain, by the rapid development of this organ in early life, its 
feeble consistence, its great impressibility by the emotions, and the 
thinness of the covering which protects it from external agencies. 

Some of the most interesting of the cerebro-spinal diseases 
which are to engage our attention, are peculiar to early life, as 
tetanus nascentium. The diseases of this system also contrast 
with other local affections in their greater obscurity, especially in 
their commencement ; for while diseases of the thorax can be 
readily ascertained by auscultation and percussion, or those of the 
abdomen by the nature of the evacuations or the degree of tender- 
ness or distension, our means of conducting examination through 
the bony encasement of the cerebro-spinal axis are meagre and 
unsatisfactory. The condition of the brain and spinal cord must 
be determined, chiefly, by the study of symptoms, and not by 
direct examination. The condition of the anterior fontanelle in 
young infants, however, enables us to determine the presence or 
absence of active congestion of the brain. If there is an excess of 
arterial blood, it is convex. Prominence of the fontanelle is com- 
mon in inflammatory and febrile diseases, and is a sign of con- 
siderable diagnostic and prognostic value. 

"Within a few years, the ophthalmoscope has been employed as a 
means of diagnosis in cerebral diseases, and although the employ- 
ment of this instrument for such purpose is but recent, enough has 



296 DISEASES OF THE CEREBRO-SPINAL SYSTEM. 

been elicited to prove its great value as an aid in determining the 
state of the brain. Prof. H. D. Noyes remarks on this subject : 
" . . . The argument for making ophthalmoscopic examination in 
all cases of brain disease, becomes irresistible. Indeed, a moment's 
reflection would lead to this conclusion without any considerations 
drawn from pathology. The optic nerve is only an outlying por- 
tion of the brain ; its extremity is fully exposed to view. Situated 
within about two inches of the brain, it is the only nerve in the 
body which we Can inspect ; it contains bloodvessels which com- 
municate directly with the intra-cranial circulation. "We thus 
come into relation with the cerebrum, by continuity of nerve- 
structure and also of bloodvessels." 

Structural changes in the optic nerve and retina have been 
discovered by means of the ophthalmoscope in meningitis, hydro- 
cephalus, phlebitis of the sinuses, apoplexy, etc. Among the 
lesions which have been observed by this instrument, are hype- 
remia, more or less opacity and tumefaction of the optic nerve, 
engorgement of the vessels of the retina, with serous or sero- 
fibrinous exudation and ecchymotic points. In certain protracted 
diseases, as chronic hydrocephalus, in which dimness or loss of 
sight occurs, the ophthalmoscope discloses a state of atrophy of 
the optic nerve. Heretofore the ophthalmoscope has been chiefly 
employed by oculists, but as it comes into more general use, there 
can be little doubt that it will be recognized as an important aid 
in the diagnosis of obscure cerebral diseases. 

Still, with all possible aids to diagnosis, the obscurity which 
attends the invasion of many of the cerebro-spinal diseases must 
be acknowledged. To the hasty and careless physician, their 
symptoms are often deceptive. Careful weighing of the. phe- 
nomena, and thorough and protracted examination, are requisite in 
order to insure correct diagnosis and proper treatment. Some of 
the cerebro-spinal affections are, in reality, sequelae of other dis- 
eases, as, for example, spurious hydrocephalus; and some are, 
strictly speaking, only symptoms, as convulsions ; but, on account 
of their importance, and because they require special treatment, it 
is proper to consider them as diseases per se. 

The brain presents certain peculiarities in infancy and childhood. 
In the foetus, while the other organs are well formed, the brain, 
especially its cerebral portion, is still diffluent, and at birth it has 
so little consistence that it must be handled carefully to prevent 
laceration. This softness is due to the large proportion of water 



DISEASES OF THE CEREB RO - SPIN AL SYSTEM. 297 

which it contains. The following analyses show the composition 
of the brain in the three periods of life: — 

Infant. Youth. Adult. 

Albumen 7.00 10.20 9.40 

Cerebral fats 3.45 5.30 6.10 

Phosphorus 80 1.65 1.80 

Osmazone, salts 5.96 8.59 10.19 

Water 82.79 74.26 72.51 

At birth the brain has a nearly uniform white color. The gray 
substance, in which the nervous power originates, is undeveloped. 
The date of its appearance corresponds with the first exhibition of 
emotion or intelligence, and the decided gray color which we 
observe in the brain of the adult does not appear until the age of 
full mental activity. 

In the new-born the brain is large in proportion to the rest of 
the body, and its growth during infancy and childhood is rapid. 
Until the fifth year, as appears from the observations of Dr. Pea- 
cock, its weight is about one-seventh or one-eighth that of the 
entire system, the proportions varying somewhat in different cases. 

The brain does not attain its full size, as stated by Dr. West, at 
the age of seven years, but, according to Dr. Peacock's statistics, it 
continues to increase till the age of twenty-five or thirty, although 
its growth is less rapid after the age of seven years than previously. 

The membranous covering of the cerebro-spinal axis is scarcely 
less interesting to the pathologist than the axis itself. I shall 
speak in the following pages of the arachnoid and cavity of the 
arachnoid, for convenience of description, although aware of the 
fact that some eminent authorities, as Virchow and Kolliker, whose 
opinions in reference to the minute anatomy of the system always 
command attention, if not assent, believe that there is no arach- 
noid, but what has heretofore been called by this name is on the 
one side the smooth surface of the dura mater, and on the other of 
the pia mater. 

The dura mater is seldom involved in the diseases of early life, 
except as it is affected by pressure, while the pia mater and arach- 
noid are the seat and source of some of the most important diseases, 
as meningitis, meningeal apoplexy, etc. 

The more complicated and delicate the structure of an organ, 
the more liable it is to errors of nutrition and growth. There is, 
therefore, no organ which is so liable to irregular development as 
the brain. It may be entirely wanting ; or it may be partially 
developed, certain portions being absent; or, lastly, its growth may 
be excessive, constituting a true hypertrophy. 



298 



ACEPHALUS — ANENCEPHALUS, 



CHAPTER I 



ACEPHALUS— ANENCEPHALUS. 



Entire absence of the encephalon is not common, but there are 
many cases of this monstrosity on record. In extreme cases the 
head and part of the neck, as well as the brain and medulla oblon- 
gata, are absent. "When there is great deficiency, there is often a 
twin, the presence of which has interfered with the full develop- 
ment of the system. Sometimes the growth of other organs besides 
the brain is imperfect. 

Anatomical Character. — In the ordinary form of anencephalus, 
the brain and sometimes the medulla are absent, with the absence 
or imperfect development of their membranous and osseous cover- 
ing. The vault of the cranium is absent. There is deficiency of 
the frontal, parietal, and occipital bones, except those portions 
which are near the base of the cranium. These portions are very 
thick and closely united, as if there were the usual amount of 
osseous substance, but instead of expanding into the arch, it had 
collected in an irregular mass at the base of the cranium. 

The absence of the brain and the cranial arch gives a remarka- 
ble appearance. The eyes are prominent, the neck thick and short, . 

while the body and limbs are ordi- 
narily well developed. The physiog- 
nomy has been compared to that of 
some of the lower animals. 

The base of the cranium is often 
occupied by a vascular tumor, not 
large, but of different size in differ- 
ent cases, and continuous below with 
the spinal pia mater. This vascular 
tumor is the representative of the 
cranial pia mater, and its smooth sur- 
face is the analogue of the arachnoid. 
The dura mater and the scalp being absent, the exposed mass re- 
sembles very much in appearance, as it does in structure, the pla- 
centa, and the sensation which it imparts to the finger pressed upon 




IMPEEFECT BRAIN. 299 

it is very similar. Sometimes small portions of cerebral matter 
are found among the vessels of this tumor, hut they are so discon- 
nected or isolated that they do not perform, in any way, the func- 
tion of a brain. Occasionally the vascular tumor is absent, and the 
medulla or upper extremity of the spine is exposed, or it terminates 
in a little papilla at the back of the neck. 

Those portions of the cranial nerves which lie external to the 
cranium are well developed, although the intra-cranial parts may 
be absent. 

Symptoms. — The respiration in anencephalous monsters is irre- 
gular. They can be made to cry, but their cry is a sort of sob or 
'hiccup, and, occasionally, they even nurse. The digestive function 
is well performed, and regular urinary and fecal evacuations occur. 
There is a tendency in anencephalous monsters to convulsions. 
Blowing upon them, and pressure upon the projecting medulla, if 
this is present, frequently produce this effect. 

Prognosis. — Fortunately these monsters are short-lived. If the 
medulla oblongata, which is essential to the maintenance of respi- 
ration, is absent, extra-uterine life is impossible. Stillbirth is the 
result. If the medulla oblongata is present, although respiration 
and circulation are established, death commonly takes place within 
two or three days, and almost always within the first week. Con- 
vulsions sooner or later occur, ending in fatal coma. 



CHAPTER II. 

IMPERFECT BRAIN. 

Between the absent and complete brain there are various grades 
of deficiency. Parts of the brain may be perfect, while other 
portions are either absent or imperfectly formed. The deficiency 
is usually in the superior parts of the brain, especially in the hem- 
ispheres of the cerebrum, while the base of the organ is perfect. 
Both hemispheres may be absent, or one may be absent, while the 
other hemisphere is shrivelled or rudimentary. Occasionally the 
cranium preserves its normal shape and size, in consequence of an 
increase in the cerebro-spinal fluid proportionate to the lack of 
brain-substance. The imperfect development is not then apparent 
to the observer. The rudimentary hemispheres in these cases are 



300 IMPERFECT BRAIN. 

spread out, forming the walls of a sac inclosing the liquid. The 
post-mortem examination of the following case was made in the 
Nursery and Child's Hospital, of this city, in 1862. 

Case. — Female ; parentage healthy ; she was plump and well formed 
at birth, and nothing unusual was observed in her condition, as she 
nursed and throve like other children, till she reached the age when 
there is, usually, the first manifestation of intelligence. With her there 
was no evidence of an intellect, or if any, it was very indistinct. She 
nursed, or took food when placed in her mouth, but apparently without 
relish, as if instinctively. She never reached her hands towards the 
nurse, or towards playthings. So indifferent and apparently uncon- 
scious was she of objects around her, that it was thought for some time 
that she was blind. She never smiled, except when her hands were 
gently rubbed or shaken ; and then the smile seemed to be more a reflex 
movement than emotional. The smile was immediately succeeded by a 
fixed vacant look. She usually lay quietly, with her arms crossed ; and 
during the last months of her life she sometimes uttered a scream, like 
children with cerebral diseases. Her evacuations were regular, and she 
was not subject to vomiting, before she was attacked with the acute dis- 
ease of which she died. The size of her head was rather less than usual 
at her age, but not less than is often seen in well-formed children. The 
forehead was small in proportion to the rest of the head, but the differ- 
ence was not such as to attract attention. Fortunately, the existence 
of this idiot was terminated by an attack of entero-colitis. 

Sectio Cadav. — The head was measured, but the measurements were 
lost. They did not seem to differ materially from the normal standard. 
The sutures were united, and the fontanelles nearly, if not quite, closed. 
The frontal bone lay a little lower than the plane of the parietal. The 
meninges of the brain presented nearly their normal appearance, but 
were distended with transparent serum. The quantity of fluid was esti- 
mated at about two-thirds of a pint, and when it was evacuated, the 
floor of the lateral ventricles was brought into view. There was almost 
an entire absence of that part of the brain which lies above the floor of 
the ventricles. On close inspection, rudimentary cerebral hemispheres 
were found in a thin layer forming a part of the walls of the sac. The 
whole amount of brain-substance above the ventricles did not exceed 
the size of a small egg. The cerebellum, the base of the brain, and 
cranial nerves presented their usual appearance. The entire brain, after 
being a few days in diluted alcohol, weighed six and a quarter ounces. 

In this case, the fluid was only sufficient to compensate for the 
deficiency of the brain. In other, and probably the larger number 
of cases of incomplete brain, the cerebro-spinal fluid is not mate- 
rially increased. There is then but slight elevation of the frontal 
bone, the forehead is low, or retreating, or even almost absent. 
This is that shape of head which is universally regarded as char- 
acteristic of idiocy. 

Symptoms. — The symptoms in cases of deficient brain relate to 
the mind. If the cerebral hemispheres are absent, there is no in- 
telligence. The individual, as regards mental endowments, does 



MICROCEPHALUS — ATROPHY OF BRAIN. 301 

not rise above the instincts of the lower animals. If the hemi- 
spheres are partially developed, there is a degree of intelligence 
proportionate to the amount of cerebral substance present. If the 
deficiency is confined to one side, there is no apparent lack of intel- 
ligence or mental capacity, since, the brain being a double organ, 
one side performs the function of both. 

Prognosis. — The prognosis as regards life, in cases of imperfect 
brain, depends not so much on the amount of deficiency as the 
exact seat of arrested growth. If only the cerebrum is partially, 
or even entirely absent, the infant may live and thrive. But if 
those portions lying at the base of the brain, which control the 
functions of animal life, are lacking, or are imperfectly formed, life 
is very uncertain, and probably short. 

It is evident that no therapeutic treatment can remedy a con- 
genital deficiency. The services of the physician are not required. 
The philanthropic and patient teacher may impart a degree of intel- 
ligence to the idiotic, and the instruction of these unfortunates has 
of late years been very successful. 

Microcephalus— Atrophy of Brain. 

An abnormally small brain, or microcephalus, as it is termed, 
sometimes results from premature closing of the sutures and fon- 
tanelles. If ossification is so rapid that the cranial bones are 
firmly united, and are of such thickness as to be unyielding at the 
time when the growth of the brain is most active, the full devel- 
opment of this organ is necessarily prevented. The brain is com- 
pressed, its convolutions flattened, and the functions of the organ 
are imperfectly performed. Death, sooner or later, is the common 
result ; life ends in convulsions and coma. 

Again, the brain of the child, when undergoing development, 
with the cranial bones sufficiently yielding, may not only cease to 
grow, but may even diminish in size, in consequence of protracted 
and exhausting diseases. Diminution in the size of the brain occurs 
especially after fevers and diarrhceal affections of long standing 
and attended with much emaciation. The waste of the brain 
corresponds with the general loss of flesh. If the cranial sutures 
are not united, the occipital and sometimes the frontal bones are 
depressed, according to the diminished size of the brain, and are 
overlaid by the parietal. In foundlings of two or three months, 
this loss of brain-substance is often very striking. In infants of 
this class who have died of protracted diarrhoea, it is not unusual 



302 HYPERTROPHY OF BRAIN. 

to observe the occipital bone not only depressed, but extending 
one, two, or even three lines underneath the parietal. 

If the child with shrunken brain, from protracted and exhaus- 
tive disease, is old enough to express its thoughts, it often seems 
foolish, talks but little, and perhaps says the same thing over and 
over again. In one case in my practice, a litle girl, having passed 
through a long course of typhus, persistently repeated during her 
convalescence, with a silly smile, the questions addressed to her. 
This peculiarity continued two or three weeks, although her appe- 
tite was good, and her restoration to health rapid. In another case 
a little boy, during convalescence, was wont to laugh heartily at 
the appearance of the ordinary articles of furniture in the room. 
Both showed more derangement of mind during convalescence 
than in the midst of the fever. The friends of such children are in 
a state of great anxiety lest their minds are permanently impaired, 
but, as the appetite and strength return, the nutrition of the brain 
is re-established, and the mind regains its former vigor. In cases 
of wasted brain, with cranial bones united, the deficiency is sup- 
plied by serous effusion, which is gradually absorbed as the health 
of the patient is re-established, and the brain enlarges. This effu- 
sion occurs not only over the convexity of the brain, but also at 
its base, and sometimes in the ventricles. Dr. West states that in 
atrophy of the brain, from protracted disease, its texture is firmer 
than usual. I have not noticed this in infants, but my attention 
has not been directed particularly to this point. It is probable 
that there is some change in the anatomical character of the brain, 
aside from mere waste. 

Partial atrophy of the brain sometimes, also, occurs from pri- 
mary disease located in this organ ; the affected portion wastes, 
while the rest retains its normal development. 



CHAPTER III. 

HYPERTROPHY OF BRAIN. 



In contrast with atrophy of the brain is the opposite state, or 
hypertrophy. The size of this organ within the limits of health 
varies greatly in different individuals, but sometimes there is so 
great an increase in volume as to properly constitute a disease. 



PATHOLOGICAL ANATOMY. 303 

Pathological Anatomy. — The excess of growth which charac- 
terizes this disease has been ascertained to be confined to the white 
portion of the brain, and ordinarily to that part contained in the 
cerebral hemispheres. Hypertrophy of the brain is attended by 
induration, which exists in different degrees in different cases. It 
is in some so slight as to be scarcely appreciable ; while in others 
it is apparent at once by pressure with the finger, or incision with 
the scalpel. Rilliet and Barthez state that the induration in 
some cases resembles in degree and appearance that produced by 
the action of alcohol. The white substance of the cerebrum is 
not only resisting and elastic, but its color is unusually pale ; it 
presents even a brilliant or polished appearance. At the same 
time the gray substance is more or less faded, and its depth in the 
convolutions is less than in the normal state of the organ. Boki- 
tansky says : " The cineritious matter is generally of a pale gray- 
ish-red color. The medullary is always dazzling white, and remark- 
ably pale and anaemic." An unusual case is related by Burnet, in 
which the gray substance in the corpora striata retained its usual 
color, and was indurated like the white substance. In exceptional 
cases the cerebellum as well as cerebrum undergoes hypertrophy, 
becoming at the same time more or less indurated. In Burnet's 
case there was induration of the optic nerves. " The internal struc- 
ture," he says, " of the optic nerves, especially in their bulbs, had 
the polish, homogeneous appearance, elasticity, and almost the 
hardness of cartilage." Eilliet and Barthez state that in two cases 
the spinal cord presented even more marked induration than the 
encephalon. Congestion is not a feature of hypertrophy. On the 
other hand, there is often less vascularity of the brain and its 
membranes than in the healthy state. If the cranial bones are 
completely ossified at the time when hypertrophy commences, and 
firmly united, enlargement of the brain is partially prevented. 
The convolutions are then thin, much flattened, the sulci more or 
less effaced, the membranes pale and dry, and the ventricles are 
small and nearly destitute of serum. At the autopsy of such a 
case, when the dura mater is incised, the expansion of the brain 
prevents the proper refitting of the skullcap. Occasionally hyper- 
trophy causes more or less absorption of the cranium, and perhaps 
the sutures already united are pressed apart. 

If hypertrophy commences in young infants with the fontanelles 
and sutures still open, they usually remain open, or are a long time 
in uniting. The interspaces continue, not only in consequence of 
the growth of the brain, which tends to separate the bones, but 



304 HYPERTROPHY OF BRAIN. 

also in consequence of feeble ossification. The shape of the head 
arrests attention. Hypertrophy usually produces most enlargement 
between and above the ears, while the frontal portion of the head, 
though somewhat enlarged, is less developed. 

The direction of the eyes is not changed, as is common in con- 
genital hydrocephalus. 

Rokitansky says (vol. iii. page 285): "With regard to the 
question to be decided by the theory and microscopic examination, 
as to the nature of the added material upon which the increase of 
volume depends, I have formed the following opinion from repeated 
investigations : — 

"1. The disease is genuine hypertrophy. 

"2. It consists, as such, not in an increase in the number of 
nerve-tubes in the brain, from new ones being formed, nor in an 
increase in the dimensions of those which already exist, either as 
thickening of their sheaths, or as augmentation of their contents, 
by either of which the nerve-tubes would become more bulky; 
but, 

" 3. It is an excessive accumulation of the intervening and con- 
necting nucleated substance." 

It is now generally admitted that the views of Rokitansky are 
correct, that hypertrophy of the brain is due to an augmentation 
in the amount of connective tissue, which lies between and unites 
the tubules. 

Causes. — Hypertrophy of the brain is commonly associated with 
rachitis or scrofula, or some error in the nutritive process, which 
shows itself in other parts of the system as well as the brain. 
Rilliet and Barthez consider frequent congestion of the brain as a 
common cause of hypertrophy. This disease is not common in 
this country. It is most frequently met in hospitals for children, 
and among the poor of the cities, whose systems are rendered 
cachectic by residence in damp and dark localities, and by unwhole- 
some diet. In the deep valleys of Switzerland, and in parts of 
South America and Asia, hypertrophy of the brain is common, 
under the name cretinism. It is associated with rachitis and 
stunted growth. The abnormal development which occurs in cre- 
tinism begins in infancy or early childhood, and the unfortunate 
subjects of it are short-lived. Cretinism has been attributed to a 
residence in localities wet and deprived in great measure of solar 
light, and to general disregard of the laws of health on the part 
of those affected as well as their parents. A recent thorough 
examination of the subject lends support to the view that it is 



SYMPTOMS. 305 

caused by the use of water containing one of the combinations of 
sulphur and iron. 

The observations of different physicians also establish a connec- 
tion between some cases of hypertrophy and the saturation of 
the system by lead. In what way lead-poisoning leads to hyper- 
trophy is obscure, but the concurrent testimony of different ob- 
servers is so strong, that we cannot doubt that it does sometimes 
have that effect. 

Symptoms. — The symptoms, as is the case with most organic 
diseases of the brain, vary considerably in different cases. Some- 
times there is, at first, more or less depression or languor. If the 
child is old enough to speak, he may complain of pain in the 
abdomen or limbs, evidently neuralgic, or of headache. After a 
variable time vomiting succeeds, and finally convulsions, affecting 
the muscles of the face, as well as extremities ; the convulsions 
are usually clonic, but sometimes, as regards at least the extremi- 
ties, of a tonic character. The pupils may be contracted or dilated ; 
there is restlessness alternating with drowsiness, and finally coma 
succeeds. 

Hypertrophy may continue a considerable time before serious 
symptoms arise ; but when once developed, these symptoms ordi- 
narily continue with more or less severity till death. Death 
commonly results within a week after their commencement, but 
sometimes not till several weeks have elapsed. When death oc- 
curs at an early period in the disease, there is usually firm ossifi- 
cation and union of the cranial bones, and, therefore, but moderate 
enlargement of the cranium. 

If hypertrophy commences at a period not far removed from 
birth, the bones, of course, yield more readily to the pressure, and 
acute symptoms do not occur so soon. After a time, however, in 
all or nearly all cases, convulsions supervene. These indicate the 
gravity of the disease, and are prognostic of its fatal termination. 

In a patient observed by Burnet, violent convulsions, followed 
by loss of consciousness, marked the commencement of acute symp- 
toms. Five days subsequently, the following symptoms were 
recorded: mobility of the eyes, without expression; pupils con- 
tracted, and directed upwards ; divergent strabismus of the left 
eye ; the senses in their normal state, with the exception of sight ; 
the limbs move by volition. For a month there was little change. 
Then occurred drowsiness, and increased prostration, and fi.ve 
weeks later the child succumbed w T ith the symptoms of double 
pneumonia. 
20 



306 HYPERTROPHY OF BRAIN. 

Such is the clinical history of hypertrophy. In cases of firm 
ossification of the cranial bones, and, therefore, no marked enlarge- 
ment of the skull, the symptoms are similar to those which occur 
if the dimensions of the head are increased, only compression and 
death result sooner. 

The following case, in which the sutures were firmly united, I 
attended in 1864. The head was large, but not so large as to 
attract attention from its disproportion. 

Case. — A boy, aged two years and two months, had, when about one 
year old, fever and ague, and since then his countenance was uniformly 
pallid, and his flesh soft. Weaned at the usual time, he remained well 
till the first of January, 1864. In the beginning of this month he was 
observed to be feverish for some days, and his appetite poor. His health 
then gradually improved, and he was thought to be entirely well. 

On the 26th of February he was suddenly seized with convulsions, 
general at first, but most severe and continuing longest on the left side. 
The convulsions lasted a little more than three hours. He recovered 
fully his consciousness by the following day, but his appetite remained 
poor; he was no longer amused by his playthings, and was very fretful. 
The surface was pallid; bowels constipated; pulse but little, perhaps 
not at all, accelerated. He continued in this state till the 6th of March, 
when he had another slight convulsive attack, and from this time he 
never fully recovered his consciousness. He was fretful if disturbed, 
his face generally pallid, while the pulse and respiration were not per- 
ceptibly altered. 

On the following day, the 7th, the left pupil was somewhat larger 
than the right, but both were sensitive to light. The difference in size 
continued till near the close of life. Although vision was imperfect, if 
not altogether lost, the sense of hearing was not impaired. 

When questioned, he uniformly answered " No," with a drawling 
voice, evidently not understanding what he said. 

As the disease advanced, the respiration became at times sighing; but 
the rhythm of the pulse was not materially altered. The temperature 
of the surface was changeable, sometimes cool, sometimes warm, and 
the congested spots or patches, so common in cerebral affections, were 
also observed at times on the face, ears, or forehead. Through most 
of his sickness, he took drinks readily, and the urine was freely dis- 
charged, probably from the iodide of potassium, which he took in one 
and a half grain doses every two hours. 

He became more and more drowsy, again had slight convulsive move- 
ments, and finally died, with much apparent suffering, on the 14th of 
March. The pulse became more accelerated during the last two or three 
days. On the day preceding his death, the pupils were contracted, and 
not affected by the light. 

Sectio Cadav. — Body somewhat emaciated, and eyes sunken; occipito- 
frontal circumference of head nineteen and a half inches ; distance from 
one auditory meatus to the other over the vertex, thirteen and a half 
inches; convolutions over the surface of the brain much flattened and 
compressed; brain generally deficient in blood; medullary substance 
firm, and of a pure white color; meninges healthy; no other abnormal 
.appearances were observed; weight of brain forty-two ounces. 



DIAGNOSIS — PROGNOSIS. 307 

Diagnosis. — The diagnosis of hypertrophy is not always easy. 
The symptoms are, in the main, such as occur in other pathological 
states, especially congenital hydrocephalus. There is most danger 
of mistaking the overgrowth for this disease. Hypertrophy has, 
indeed, often been treated for hydrocephalus. There are, however, 
certain signs by which we may distinguish one from the other. 
In the ordinary form of congenital hydrocephalus, even when the 
amount of liquid is small, the orbital plates of the frontal bones 
are pressed in such a way that the axis of the eyes is changed so 
as to have a downward direction. The white of the eye can be 
seen between the iris and the upper eyelid. This gives a charac- 
teristic and striking expression to the face. The exception to this 
is in those rare cases in which the liquid is external to the brain. 
In hypertrophy this peculiar change in the axis of the eyes does not 
occur. Moreover, in hypertrophy there is not that uniform expan- 
sion of the head which is observed in hydrocephalus, as has been 
stated above. There are, commonly, greater enlargement, more 
prominence of the anterior fontanelle, and wider separation of the 
cranial bones, in hydrocephalus than in hypertrophy. 

Hypertrophy with consolidation of the cranial bones, and, 
therefore, little enlargement of the head, may be mistaken for 
meningitis. The history of the case, and the means by which we 
diagnosticate the latter affection, which will be described in their 
proper place, will usually enable the physician to make a correct 
diagnosis. 

Prognosis. — In forming an opinion as to the probable termination 
of the disease, we must have regard to the age and general condi- 
tion of the child, as well as to the degree of hypertrophy. If the 
disease commence at an early age, when the cranial bones are not 
firmly united, it is probable that there will be no compression of 
the brain, so as to endanger life, for a considerable period. We 
may then hope by proper measures to remove the constitutional 
state which gives rise to the hypertrophy, before the enlargement 
is such as to cause cerebral symptoms. If the bones have already 
united when the disease commences, even slight hypertrophy will 
produce symptoms, and a speedily fatal result is inevitable. Evi- 
dently, also, a child in a marked degree rachitic or scrofulous is 
much less likely to recover than one whose general health and 
constitution are less impaired. 

Treatment. — The treatment in hypertrophy should be directed 
mainly to the constitution. Measures calculated to improve the 
nutritive process are those most likely to check the abnormal 



308 THROMBOSIS IN THE CRANIAL SINUSES. 

growth of the brain. As the disease is one of perverted nutrition, 
and usually coexists with a vitiated or impoverished state of the 
blood, tonic and alterative remedies are required. The liquor 
ferri iodidi is, therefore, useful, as it is both tonic and alterative. 
This may be given in doses of three or four drops to a child one 
year old, three times daily. Cod-liver oil, with or without the 
iron, is beneficial in some cases. Another remedy is iodide of 
potassium in combination with a tonic, as the compound tincture 
of bark. 

R:. Potas. iodid. 5j 5 

Tinct. cinchon comp., 
Syr. limonum, aa §ij. Misce. 
One teaspoonful, three times daily, to a child of three years. 

The hygienic treatment is not less important than the medicinal. 
There is little hope of a favorable issue in any case, unless the 
regimen is such as will conduce to a more robust and healthy 
state of system. The diet should be plain and nutritious, the 
apartments clean and airy, and all undue excitement should be 
avoided. 



CHAPTER IV. 

THROMBOSIS IN THE CRANIAL SINUSES (PHLEBITIS). 

The formation of fibrinous coagula within a vein or sinus is 
designated thrombosis (thrombus, clot). Coagulation of fibrin in 
the cranial sinuses occasionally occurs, constituting a very serious 
pathological state. This may result from local disease in the 
sinuses or in their vicinity, or from disease external to the cranium. 
The immediate cause of thrombosis, whatever its location, is suffi- 
cient arrest of the circulation to allow the fibrin to coagulate. 

Tubercular and enlarged bronchial glands, compressing more or 
less the vense innominatse or the descending vena cava, sometimes 
give rise to thrombosis in the cranial sinuses, the fibrin coagulating 
in consequence of retardation in the current of blood. I have 
known thrombosis, in the same situation, also to result from clonic 
convulsions, occurring in connection with severe spasmodic cough 
in pertussis, since both the cough and convulsions retard the flow 
of blood in the veins and sinuses within the cranium. At the 



ANATOMICAL CHAKACTEES. 309 

post-mortem examination of two such cases I found firm whitish 
clots in the lateral sinuses. 

Thrombosis, in the cranial sinuses, may also occur from inflam- 
mation either in the walls of the sinuses, or immediately exterior 
to them. This is the disease which writers have designated 
phlebitis of the cranial sinuses, and for a correct understanding 
of the morbid anatomy of which the profession are indebted to 
Yirchow. 

Anatomical Characters. — If a child die with the cranial 
sinuses and the veins of the brain and of the meninges in their 
normal state, the blood in these vessels is found at the autopsy 
dark but liquid, or there are small, dark, and soft clots in the larger 
sinuses. If there was congestion, but no coagulation, in these 
vessels in the last hours of life, the clots are more numerous, 
larger, and longer, sometimes extending from the sinuses into the 
larger veins which empty into them, but they are still dark and 
soft, readily falling to pieces when handled. If, again, there has 
been that degree of congestion and stasis which has resulted in 
ante-mortem coagulation, or in thrombosis, the clots are, in part at 
least, whitish, and of a fibrinous or gelatinous appearance ; they 
were formed while the red corpuscles were still carried along in the 
circulation. 

Most of the clots in thrombosis are free, while others are at- 
tached lightly to the internal surface of the sinus ; occasionally 
they are so large as to distend the vessel. They extend also in 
many cases into the cerebral veins which connect with the sinuses, 
producing prominence and firmness, so as to resemble (Rilliet and 
Barthez) an artificial injection. The clots do not present a uniform 
character. In parts of a sinus they consist of almost pure fibrin, 
of a yellowish- white color, while in other portions they present a 
gelatinous appearance from the large number of white corpuscles, 
while other portions are more or less tinged from the presence of red 
corpuscles. The central part of the clot, after a time, if the case is 
sufficiently protracted, softens, and presents a puriform appearance. 
This substance, which is only disintegrated fibrin, was supposed 
to be pus, till the microscope revealed its true character. It is 
obvious that small clots forming within a sinus, and having no 
attachment to its walls, are liable to be carried by the current of 
blood into the general circulation, unless there is complete obstruc- 
tion, Virchow has also shown how a thrombus may extend, by 
gradual prolongation, nearer and nearer the heart, so that one 
commencing in a sinus may, after a time, reach into the jugular 



310 THROMBOSIS IN THE CRANIAL SINUSES. 

vein. Different observers, as M. Tonnele, and also Rilliet and 
Barthez, have traced the fibrinous masses as far as the cava. The 
latter writers relate the case of a girl, four and a half years old, 
in whom the sinuses on the left side, especially those nearest the 
petrous portion of the temporal bone, were completely filled with 
clots of a yellowish- white color, intermixed with central dark 
spots. Similar coagula were also found in the left j ugular vein as 
far as the brachio-cephalic trunk. "Whether the walls of the sinus 
undergo any change depends on the nature of the disease which 
causes the thrombosis. If it be phlebitis, the coats are thickened 
from infiltration and injected, and the internal coat has lost its 
polish. If it be some obstructive disease in the course of the 
circulation, or a general cause, the coats of the vessel are unaltered, 
except that they may be stained by imbibition of the coloring 
matter of the blood. In an infant who died of this disease in the 
practice of Dr. West, "the sinuses on the left side were healthy, 
but the blood was almost entirely coagulated. The posterior half 
of the longitudinal sinus, the torcular, the left lateral, and the left 
occipital sinuses, were blocked up with fibrinous coagulum, pre- 
cisely such as one sees in inflamed veins, and the clot extended into 
the internal jugular vein. The coats of the longitudinal, and of 
the inner half of the lateral sinus, were much thickened, and their 
lining membrane had lost its polish, was uneven, and presented a 
dirty appearance." 

The mode in which congestion and coagulation occur within a 
sinus, in consequence of the pressure of a tumor upon this vessel, 
or upon a vein into which the blood from this sinus flows, is suffi- 
ciently obvious. The mode of the production of thrombosis, as a 
result of clonic convulsions, or of the spasmodic cough of pertussis, 
is also apparent. How it results from inflammation of the walls 
of a sinus, that is, from phlebitis, was not understood till explained 
by Virchow. 

The fibrinous coagula which fill the sinus are not an exudative 
product, as was formerly supposed. Inflammation (in most cases 
otitis, with caries of the petrous portion of the temporal bone) 
approaches a sinus. The inflammatory products pressing against 
the walls of the sinus diminish its calibre at that point, and hence 
the retardation of the current of blood and the coagulation. Or 
the walls of the sinus may be thickened by inflammatory infiltra- 
tion, or even by the formation of little abscesses within the coats 
in consequence of the inflammation, so as to produce bulging 
inwards, and the result, as regards the circulation, is the same. 



CAUSES. 311 

Whether, therefore, the inflammation occur without a sinus, or 
within its walls, thrombosis equally results, provided that the 
diameter of the vessel is sufficiently narrowed by the presence and 
pressure of inflammatory products. 

There is no exudation on the internal surface of a sinus or vein 
when inflamed, as there is upon serous surfaces. "On the con- 
trary" {Cellular Pathology, translation, p. 236), "when the wall is 
inflamed, the exuded matter (exsudatmasse) passes into the wall, 
which becomes thicker, cloudy, and subsequently begins to sup- 
purate. !Nay, even abscesses may form which cause the wall to 
bulge on both sides like a variolous pustule, without any coagula- 
tion of the blood ensuing in the cavity of the vessel. At other 
times, certainly, phlebitis, properly so called (and in like manner 
arteritis and endocarditis), is the cause of thrombosis, in conse- 
quence of the formation of inequalities, elevations, depressions, and 
even ulcerations upon the inner wall which favor the production 
of the thrombus. Still, whenever phlebitis, in the usual sense of 
the word, takes place, the alteration in the coat of the vessel is 
almost always a secondary one, and, indeed, occurs at a compara- 
tively late period." 

This view of the pathology of thrombosis comports with facts 
observed at autopsies, and which cannot be explained according to 
the old theory of phlebitis, namely, smoothness of the internal 
surface of the sinus ; natural color of this sinus, or simple stain- 
ing from blood ; the non-attachment or slight attachment of the 
coagula, etc. 

Causes. — Some of these have been already stated at the com- 
mencement of this article. It is evident from what has been said 
that this disease may be produced by any cause which obstructs 
the return circulation from the head. I have already alluded to 
tumors which press upon the sinus, or on the vein below the sinus, 
as a cause. Among the causes may be mentioned also abdominal 
tumors, narrowing of the chest from rachitis, or caries of the ver- 
tebrae, and, finally, compression of the jugular vein by a retro- 
pharyngeal abscess. 

Sufficient allusion has already been made to inflammation of the 
internal ear as a not infrequent cause. Thrombosis is, indeed, the 
most dangerous result of chronic otitis. Another cause is a re- 
duced or cachectic state of system, apart from any local obstructive 
disease. It is a noteworthy fact that a large proportion of those 
affected with thrombosis, even when it is immediately due to ob- 
structive disease, are cachectic. The explanation of this fact is 



312 THEOMBOSIS IN THE CRANIAL SINUSES. 

not difficult. In reduced states of the system the action of the 
heart is feeble, and passive congestion of the vessels within the 
cranium is apt to occur. Passive congestion of the veins and 
sinuses in protracted diarrhceal maladies, which is described in our 
remarks upon another disease, is an example in point. In this 
state of feeble circulation very slight obstructive disease may be 
sufficient to cause thrombosis. 

Symptoms. — The symptoms of this disease are often obscure. 
All of them may and do occur in other diseases of the encephalon. 
In cases related by M. Tonnele*, cerebral symptoms were well 
marked, such as faintness, dilation of the pupils, strabismus, grind- 
ing the teeth, convulsive movements. There may be an almost 
total absence of such symptoms as would direct attention to the 
state of the head. This is due to the sudden occurrence of death 
in such cases after the clots have formed. If the clots are large, 
death soon results in consequence of congestion of the brain and 
meninges, which is proportionate to the amount of obstruction. 
Extravasations of blood and transudation of serum not infrequently 
accompany the congestion and hasten the result. 

Dr. West relates the case of a girl who had a mild attack of 
scarlet fever at the age of eight months, and did not fully recover 
her health. She continued restless and feverish, and had two vio- 
lent convulsions two weeks after the scarlatina. In the following 
months she had anasarca, and when she was nearly a year old 
another attack of convulsions occurred. Fluctuation was now 
observed in the abdomen, and in a few days a sero-purulent fluid 
began to escape from the umbilicus. "When this discharge had 
continued eleven days, symptoms of a liquid in the right pleural 
cavity were suddenly developed. She grew weak and emaciated, 
and finally was seized with extreme faintness, with which she died 
in forty-eight hours, at the age of thirteen and a half months. 

At the post-mortem examination a large amount of pus was 
found in the abdominal and right pleural cavities. On the right 
side of the cranium the sinuses, were filled with coagula, and their 
coats seemed healthy. The left lateral and occipital sinuses, the 
torcular and part of the longitudinal sinus, also contained coagula, 
which extended into the jugular vein. The walls of the longitu- 
dinal sinus and the internal part of the lateral sinus were thick- 
ened, and their inner surface had lost its polish and was uneven. 
There was congestion of the brain, with points of extra vasated 
blood. If, as is probable, the convulsions were due to some other 
cause, the only symptom which was clearly referable to the throm- 



DIAGNOSIS — PEO GNOSIS — TREATMENT. 313 

bosis was the sudden faintness. In the two cases of thrombosis 
occurring in pertussis, already alluded to, and in which I was en- 
abled to ascertain by post-mortem examination the presence and ex- 
tent of the clots, the symptoms, which were apparently due to the 
thrombosis, were those of cerebral congestion. Among these symp- 
toms, stupor, and finally coma, were prominent. The convulsions 
which occurred in both cases were apparently a cause, and not result, 
of the thrombosis. 

Diagnosis. — It is evident, from what has been said, that throm- 
bosis of the cranial sinuses can rarely be diagnosticated with 
certainty. The pre-existence of otitis will sometimes lead us to 
suspect its presence, especially if the otitis has been accompanied 
by deep-seated pains. Symptoms of cerebral congestion, serous 
effusion, or apoplexy, occurring in connection with otitis, pro- 
tracted convulsions, or glandular or other tumors situated so as to 
compress the vessels which return blood from the brain, indicate 
thrombosis. 

Prognosis. — The prognosis, in any case, is obviously unfavorable. 
The cause is, ordinarily, permanent, or not readily removed, so that 
the clots gradually increase. If the cause is local obstructive dis- 
ease, death is almost certain, since, in nearly every instance, the 
obstruction is of such a nature that it cannot be removed by medical 
or surgical treatment. It is possible that recovery may take place 
if the clots are few and small, and the cause of the thrombosis is 
mainly feebleness of circulation in consequence of a state of debility. 
"We know that clots may liquefy, and their elements re-enter the 
circulation ; but such a result of thrombosis in a cranial sinus, if 
it ever occurs, is rare. The thrombus, by its presence, serves as a 
point of attachment around which more fibrin coagulates, so that 
the obstruction gradually increases till death occurs. 

Treatment. — Thrombosis should be treated by cool applications 
to the head, in order to diminish the congestion, by stimulants and 
sustaining measures in case the systolic movement of the heart is 
feeble. Tonics, vegetable or ferruginous, are indicated if there is 
a cachectic state. 



314 CONGESTION OF BRAIN. 



CHAPTER V. 

CONGESTION OF BKAIN. 

Congestion of the brain is not peculiar to infancy and childhood, 
but is much more common in these periods of life than subse- 
quently. This is due, in a great measure, to the fact that in the 
young the circulation is more readily disturbed by moral as well 
as physical causes than in the adult. 

Congestion of the brain is occasionally primary; more fre- 
quently it occurs as a concomitant or sequel of some other affection. 
Diseases, whether constitutional or local, which in the adult have 
no appreciable effect on the vascularity of the brain, often cause 
in the child a decided increase of blood in this organ. 

Causes. — Cerebral congestion is of two kinds, active and pas- 
sive. The former results from a cause which directly affects the 
brain, and increases the flow of blood towards it, or from a cause 
operating primarily on the heart, and increasing the frequency 
and force of its systolic movement ; the latter is due to some 
obstruction in the course of the circulation, or to a feeble pro- 
pelling power on the part of the heart. 

Among the causes which most frequently produce active con- 
gestion of the brain in the child, may be mentioned blows or falls 
on the head, excessive fatigue or excitement, heat, perhaps some- 
times dentition, and also various inflammatory and febrile affec- 
tions, especially in their first stages. 

Cerebral symptoms occurring in the course of an essential fever 
are no doubt often due, in a great measure, to the irritating effect 
on the brain of the specific principle, whatever it may be, circu- 
lating in the blood. Occurring in inflammatory diseases which 
are located elsewhere than within the cranium, they are often 
attributed to functional disturbance of the brain. The brain, it is 
said, sympathizes with the affected part through the system of 
nerves which unite them. But observations show that sjmiptoms 
referable to the brain, arising in the commencement of the essen- 
tial fevers and of the phlegmasia, are in many instances preceded 
by, and are therefore, doubtless, in greater or less degree dependent 
on, hyperemia of this organ. 



CAUSES. 815 

Difficult as it is to ascertain the state of the brain in many 
diseases in which it is involved, we may determine whether or 
not there is congestion in the young child by observing the 
anterior fontanelle. If it be elevated and tense in an acute 
disease, hyperemia is indicated. Now, it is often unusually 
prominent in fevers and inflammations, especially in their first 
stages, when cerebral symptoms are present. Its elevation, under 
such circumstances, is obviously coincident with cerebral con- 
gestion. 

The acute inflammations which are most likely to be attended 
by cerebral congestion are those of the mucous surfaces, and 
pneumonia. Severe coryza, tracheo-bronchitis, entero-colitis, and 
colitis, commencing suddenly with great febrile excitement, are 
frequently accompanied in their initial stage by active congestion 
of the cerebral vessels. Cases like the following, which I find in 
my note-book, are not infrequent. An infant four months old 
had been sick about two clays with coryza and bronchitis, when 
I was called to see it ; the pulse numbered 156 ; respiration 64 ; 
nursed, and was somewhat restless; cough frequent and dry; 
bowels moderately relaxed. The mucous membrane of the fauces 
was injected, and coarse mucous rales were present in the chest. 
The anterior fontanelle rose above the level of the cranium, and 
pulsated forcibly. Soon after, convulsions occurred, which were 
relieved by appropriate measures, and on the following day the 
fontanelle had subsided. The patient gradually recovered without 
any other untoward symptom. 

Cerebral congestion and convulsions often mark the initial stage 
of active intestinal phlegmasia. This is especially true of dysen- 
tery. The little patient, perhaps from the very inception of the 
colitis, is drowsy; its surface hot; pulse full and rapid. There is 
sudden and momentary starting or twitching of the limbs. The 
anterior fontanelle, if still open, is elevated, and it is not till the 
lapse of several hours that the cause of these symptoms is apparent 
from the bloody stools. 

The causes of passive congestion of the brain are very different 
from those of the active form. A common cause is obstructions 
in a sinus or vein by a fibrinous concretion, or by a tumor or 
abscess external to it. 

I have occasionally met cases in which this form of cerebral 
congestion appeared to be plainly referable to obstruction to the 
return of blood from the brain by the pressure of bronchial glands, 
enlarged by hyperplasia in tubercular disease, these bodies dimin- 



316 CONGESTION OF BRAIN. 

ishing by external pressure the calibre of the vense innominatse or 
the descending vena cava. Pilliet and Barthez have called atten- 
tion to such cases in the clinical history of tuberculosis. The fol- 
lowing case may be cited as an example ; it occurred in the infant's 
service of Charity Hospital, in this city, in April, 1866. 

An infant, about one year old, aifected with tuberculosis, both 
bronchial and pulmonary, was observed, during the ten days pre- 
ceding its death, to bore the pillow with its head almost constantly, 
so as to wear the hair from the occiput. This movement of the 
head was the only prominent cerebral symptom. Nothing abnor- 
mal was noticed in the appearance of the eyes, nor was the stomach 
irritable. A spasmodic cough and progressive emaciation attracted 
attention, but these were referable to the tubercular disease. At 
the autopsy, we found the cerebral sinuses, veins, and capillaries 
greatly congested. On tracing the veins which return blood from 
the brain, an inflamed and enlarged bronchial gland was discovered 
in the angle formed by the convergence of the right and left vense 
innominatse. This gland, which contained but a single point of 
tubercular exudation, had attained such a volume by proliferation 
of its cells, that it pressed upon both vessels, so that it had 
obviously retarded the circulation in each, and given rise to the 
cerebral congestion. 

Passive congestion often occurs in the infant at birth, either 
from tediousness of the labor, or delay in the expulsion of the 
body after the birth of the head. If it is simple congestion, 
and not congestion with hemorrhage, it soon passes off. Passive 
congestion of the brain also occurs in severe paroxysms of 
hooping-cough, in which return of blood from this organ is 
temporarily retarded. All are familiar with the congestion which 
occurs in parts external to the cranium, from the severity of the 
cough; producing epistaxis, extravasations under the conjunctiva, 
etc. The extra-cranial obviously indicates the presence and degree 
of cerebral congestion. 

Those who practise in malarious regions sometimes meet cases 
of dangerous passive congestion of the brain, the result of malaria, 
occurring especially in the cold stage of intermittent fever. In 
these cases, the surface is pallid, its temperature reduced, and the 
pulse feeble. The blood, leaving the peripheral vessels, collects 
in undue quantity in the internal organs, producing congestion of 
the brain, as well as of the thoracic and abdominal viscera. In 
the child with malarious disease, in whom there is less vigor of 
constitution than in the adult, death not infrequently occurs in 



ANATOMICAL CHAEACTEKS. 317 

this passive congestion. Two such cases have occurred in my 
practice, although in this latitude the malarious affections are 
mild in comparison with the type which they present in many 
parts of the United States. 

Symptoms. — The symptoms of active congestion of the brain 
are stupor, great heat of head, throbbing of carotids, restlessness 
when aroused, twitching of the limbs, and perhaps convulsions. 
There is also sometimes intolerance of light, and the anterior fonta- 
nelle, if open, pulsates strongly. In passive congestion many of 
the symptoms are the same as in the active form. Stupor, twitch- 
ing of the limbs, and fretfulness or irritability when the patient is 
disturbed, are common, ordinarily without increase of temperature ; 
the surface may, indeed, be cool, and the face is not flushed nor 
the eyes injected. The strong pulsation and elevation of the ante- 
rior fontanelle, so conspicuous in active congestion, are — the former 
always, the latter often — lacking, In both forms there is a tendency 
to constipation. 

In many cases the symptoms of congestion of the brain are 
associated with others which proceed directly from the cause of 
the congestion, but it is not difficult, unless in exceptional instances, 
to determine which are due to the congestion, and which to the 
antecedent and coexisting pathological state. 

Anatomical Characters. — In active congestion there is an ex- 
cess of arterial blood in the brain and its membranes. The arte- 
ries, to their minutest branches, are seen to be full, presenting 
the bright hue of oxygenated blood. In passive congestion the 
sinuses and veins are distended. The pi a mater, choroid plexus, and 
the vessels of the brain, have a darker appearance than in active 
congestion. In both forms of congestion, if they continue for a 
little time, other anatomical changes occur. If there is great dis- 
tension of the capillaries, these vessels are apt to give way, and we 
find here and there little patches of extravasated blood. In other 
cases the over-distension is relieved by the transudation of the 
serous portion of the blood through the coats of the vessels. The 
cephalo-rachidian fluid is then found in excess external to the 
brain and in the ventricles. 

Prognosis. — The duration and the result of congestion of the 
brain depend, in great measure, on the nature of the cause. If 
the cause is trivial, as mental excitement, fatigue, exposure to 
heat, there is usually prompt relief if the condition of the patient 
is understood and properly treated. If the cause is general or con- 
stitutional, as one of the essential fevers or hooping-cough, or if it 



318 CONGESTION OF BRAIN. 

is local, but its seat external to the cranium, the prognosis, so far 
as the congestion is concerned, is not unfavorable, if there is a timely 
and judicious use of remedies. The most unfavorable cases are 
those in which the cause is seated in the encephalon, and those in 
which there is some obstructive disease in the course of the circu- 
lation. Congestion occurring from a structural change within the 
cranium is, from the nature of the cause, without remedy, and 
ordinarily fatal. Obstructive diseases of the circulatory system, 
wherever located, being for the most part permanent, give rise, as 
a rule, to incurable congestion. 

Congestion of the brain, if it is not relieved in a few hours, be- 
comes less and less amenable to treatment. It soon passes beyond 
the resources of our art, aud ends in coma ; it is seldom protracted 
beyond a few days. Extravasations of blood common in active 
congestion, and serous effusion common in the passive form, dimin- 
ish the chances of a favorable result. 

Treatment. — The indication for treatment in active congestion 
is plain. Measures should be employed which have a derivative 
effect from the brain. Unless there is an asthenic primary affec- 
tion, in the course of which the congestion is developed, active 
purgation is required. A saline purgative is ordinarily preferable. 
If the stomach is irritable, there is no better purgative than calo- 
mel. In all cases of active congestion, whatever the cause, the 
bowels should be kept open. It is often better not to wait for the 
tardy action of a cathartic, but to give at once an enema of soap 
and water or salt and water. External derivative agents are also 
indicated. A warm mustard foot-bath, sinapisms to the back of 
the neck or chest, and to the feet, and cold applications to the 
head, are measures which should never be neglected. 

This treatment, if employed early, will relieve the congestion in 
a large proportion of cases ; but if there is no improvement, if the 
child is robust, and if the primary affection be such as does not 
contraindicate loss of blood, leeches should be applied to the tem- 
ples or some part of the head. If after the lapse of some hours 
cerebral symptoms continue, apoplexy or serous effusion has pro- 
bably occurred. Congestion is then no longer the prominent lesion, 
and it is proper to designate the disease by another name. 

The treatment appropriate to passive congestion is somewhat 
different; cold applications to the head, and those of a derivative 
nature to the extremities, are useful. As this form of the disease 
is not primary, but is dependent on some antecedent pathological 
state, it is evident that it can only be treated successfully by re- 



HEMORRHAGE — CAUSES. 319 

moving or obviating as far as possible the cause. But the nature 
of the various obstructions to the intra-cranial circulation is such 
that our ability to accomplish this end is very limited. 

If the cause is constitutional, or if it be some disease in the 
neck or chest, it may sometimes be partially or even wholly re- 
moved, but if seated within the cranium it is beyond our control. 
In general, it may be said that depletion is not required or tole- 
rated in passive congestion, and occasionally stimulants are needed. 



CHAPTEE VI. 

INTRA-CRANIAL HEMORRHAGE (MENINGEAL HEMORRHAGE- 
CEREBRAL HEMORRHAGE). 

Hemorrhage within the cranium is not very infrequent in in- 
fancy and childhood; and there is no part of the encephalon, 
whether the meninges or brain, in which it does not sometimes 
occur. If the blood is extravasated upon the surface of the brain 
or between the meninges, the disease is designated by writers 
meningeal apoplexy; if in the substance of the brain, cerebral 
apoplexy. Extravasation may also occur in one of the lateral 
ventricles. This may, for convenience, be described as a form of 
meningeal apoplexy. . 

Causes. — Apoplexy is usually (there is an exception) preceded 
by congestion. If the congestion increases to a certain degree, the 
distended capillaries give way, and extravasation of blood results. 
Therefore the causes of congestion which have been enumerated 
in the preceding article are, in great measure, those of apoplexy. 
Recent microscopic examinations have demonstrated that the cor- 
puscular elements of the blood may escape from capillaries without 
rupture. "While, therefore, it is probable that intra-cranial hemor- 
rhage in early life commonly occurs from a rupture, its occasional 
occurrence through the walls of the capillaries must be admitted. 

Intra-cranial hemorrhage is not infrequent in the new-born. It 
results in them from tediousness of the birth, and severity of the 
labor-pains. At first there is extreme congestion of the meningeal 
and cerebral vessels corresponding with that of the scalp and face. 
This congestion continuing, soon ends in extravasation of blood. 
In some of these cases forceps have been used to effect the delivery, 
but it is doubtful whether the use of instruments materially in- 



320 INTRA-CRANIAL HEMORRHAGE. 

creases the congestion or the amount of extravasation. Certainly 
in a large proportion of intra-cranial as well as supra- cranial hemor- 
rhage of the new-born, instruments have not been used. An addi- 
tional cause of the hemorrhage is in some instances the use of 
ergot, which, by producing strong and continuous pains, interrupts 
the placental circulation and increases the congestion of the foetal 
veins and capillaries. 

In infants a few days old, intra-cranial hemorrhage may result 
from that rapid and fatal disease, tetanus neonatorum. The hemor- 
rhage is preceded by intense passive congestion, which the tetanic 
rigidity and spasms produce by obstructing respiration and circula- 
tion. Few cases of tetanus neonatorum occur without more or 
less extravasation of blood, either meningeal or cerebral. Another 
cause of this disease is obstruction in the vessels which return the 
blood from the brain. The various structural changes which pro- 
duce this obstruction, in different cases, have been sufficiently 
described in our remarks on cerebral congestion and thrombosis. 

The congestion which precedes hemorrhage, when occurring un- 
der the conditions described above, is passive. 

Among the causes which produce hemorrhage through the inter- 
mediate state of active congestion, may be mentioned great mental 
excitement, of which M. Legendre relates a case, lengthened expo- 
sure to the sun's rays, an example of which Killiet and Barthez 
have seen. It is also said that compression of the aorta by an 
enlarged liver or an abdominal tumor has sometimes produced 
meningeal or cerebral haemorrhage by causing an increased afflux 
of blood to the head. A very important cause to which I have 
not alluded, is that general state of the circulatory system which 
is designated by the term purpura hsemorrhagica. This sometimes 
results from the anti-hygienic conditions in which the child is 
placed. In other instances it results from some antecedent disease, 
protracted, debilitating, and which has produced a profound alter- 
ation in the state of the blood and the vessels. The capillaries 
become less firm and elastic, and easily give way, so that in such 
patients ecchymotic points are ordinarily found in different parts 
of the system. The diseases which occasionally end in this hemor- 
rhagic diathesis are numerous. I have known it to occur after 
measles, scarlet fever, and smallpox. It is also an occasional sequel 
of chronic diarrhoea, of intermittent and typhoid fevers, and of 
rachitis. 

Anatomical Characters. — Hemorrhage in or upon the brain in 
infancy and childhood, differs in important particulars from that 



ANATOMICAL CHARACTERS. 321 

occurring in adult life. In the adult, and more so as life advances, 
the arteries become less distensible and more brittle, so that when 
hemorrhage occurs it is usually from one of these vessels. In early 
life, on the other hand, the blood does not ordinarily escape from 
an artery, but, as has been stated, from the capillaries. The extra- 
vasation is not, therefore, so rapid and violent, and is not attended 
with such laceration and injury of surrounding parts, in infancy 
and childhood, as at a subsequent age. In the adult, the hemor- 
rhage commonly occurs in. the substance of the brain. The flow 
of blood from the ruptured artery separates the brain-substance, 
producing a cavity in which a clot forms. This constitutes the 
usual form of apoplexy in the adult. In the first years of life, on 
the contrary, the extravasation is commonly from .the meninges, 
and the symptoms to which the effused fluid gives rise are mainly 
referable to its mechanical effect. Cases of hemorrhage in the sub- 
stance of the brain constitute a small minority, unless during the 
days immediately succeeding birth. In early life, therefore, on ac- 
count of its greater frequency, meningeal hemorrhage is a disease 
of more importance than cerebral, and its anatomical character 
should be carefully studied. 

In meningeal hemorrhage the extravasation may be between the 
cranium and dura mater, upon the visceral layer of the arachnoid, 
in the meshes of the pia mater, or in a lateral ventricle, from 
rupture of the capillaries in the choroid plexus. Much the most 
common seat is external to the pia mater in the so-called cavity 
of the arachnoid ; the blood escaping in this situation spreads 
uniformly in all directions. It soon separates in two portions, the 
solid and liquid. The solid portion, or the clot, is free or but 
slightly attached to the adjacent membrane. The meninges in 
the vicinity of the extravasated blood preserve their normal 
appearance, or are but slightly injected ; the clot gradually be- 
comes extended on all sides, so as to form a lamina at the seat of 
the extravasation, thinner at its circumference than centre, and 
at first of a dark red color. The color gradually fades, and the 
lamina becoming smooth and polished, and at the same time more 
and more attenuated, finally resembles the arachnoid in appearance. 
Its diameter varies in different cases from a few lines to two or 
three or more inches. M. Tonnele relates two observations in 
which the adventitious membrane extended over the superior 
surface of both hemispheres, and in one of them, also, over the 
falx cerebri. 

The extravasation may occur at any part of the surface of the 
21 



322 INTRA-CRANIAL HEMORRHAGE. 

brain, but its usual seat is the vertex. The next most frequent 
locality is the base of the brain. The subsequent history of the 
delicate membrane into which the clot is gradually transformed 
is interesting. It often extends so as to cover more space than 
was occupied by the extravasated blood, and its edges are then 
scarcely distinguishable, in consequence of their extreme tenuity, 
and their close resemblance to the arachnoid. . The attachments ot 
this membrane, so far as it forms any, are usually to the parietal 
surface of the arachnoid. Sometimes a portion of the membrane 
is attached, while the rest lies free, bathed on either side by the 
liquid portion of the blood which still remains from the extravasa- 
tion. According to M. Legendre, in the most favorable cases, the 
serum is absorbed, and the membrane which has resulted from the 
clot, and which I have described, becomes intimately adherent to 
the internal surface of the dura mater. It forms an integral part 
of this membrane, and there only remain a little thickening and 
increased opacity, indicating the seat of the extravasation. The 
health is fully re-established. 

But the result in other cases is as follows. The serum is not 
absorbed, and the newly-formed membrane, uniting at points with 
the inner surface of the dura mater, or its arachnoidal covering, 
incloses the fluid so as to produce a circumscribed hydrocephalus. 

Sometimes there is only one cyst ; in other instances the mem- 
brane, especially if large, unites in such a way as to give rise to 
more cysts than one. The size of the cyst varies, according to the 
quantity of fluid, which may be only a few drachms or several 
ounces. Rilliet and Barthez report a case in which there was a 
pint of fluid lying over each hemisphere, there being two cysts. 
If the cranial bones are not united, so that they yield to the pres- 
sure, the size of the cranium is increased, and if the extravasation 
is confined to one side, an inequality results, and the symmetry of 
the head is destroyed. The fluid which causes the enlargement of 
the head in such cases, is in part the serum of the extravasated 
blood, and in part a subsequent secretion. 

Various writers relate cases of ventricular hemorrhage. Valleix 
met it in an infant that died at the age of two days. In the Edin. 
Journ. of Med. and Surg., October, 1831, an interesting case is 
related. A boy, nine years old, died of hemorrhage in both ven- 
tricles, and also at the base of the brain and in the spinal canal. 
In the Nursery and Child's Hospital of this city, the post-mortem 
examination was made of an infant who died at the age of one 
month. In the posterior cornu of the left lateral ventricle were 



CEREBRAL HEMORRHAGE. 323 

two clots, elongated and black, one larger than the other. In the 
corresponding cornu, on the opposite side, was a smaller clot. A 
similar post-mortem appearance was observed at the autopsy of a 
young infant in the infant service of Charity Hospital. A dark 
crescentic clot lay in each posterior cornu. The clot, if remaining 
a long time, undergoes degeneration. In one case of an adult, in 
which a year had elapsed after the extravasation, I found it to con- 
tain crystals of cholesterine and carbonate of lime. 

Cerebral hemorrhage, or hemorrhage in the substance of the 
brain, may occur at any time in infancy and childhood. The blood 
is sometimes extra vasated in points, here and there, over the entire 
organ, or a part of the organ ; in other cases it is extravasated in 
one or perhaps two cavities, as in the ordinary form of apoplexy in 
the adult. In the first form of cerebral hemorrhage, or that in 
which the blood escapes from numerous points through the brain, 
there is evidently little laceration or injury of the organ. The 
brain-substance surrounding the hemorrhagic points sometimes 
preserves the usual appearance. It is white and firm. In other 
cases it presents a reddish or yellowish appearance, and is softened 
to the depth of a line or two. If the hemorrhage occur in a 
cavity, as in apoplexy of adults, the nerve-fibres are evidently torn 
and separated, and there is more or less compression of the sur- 
rounding brain-substance. Unless the disease is of long standing, 
the cavity contains a dark and soft clot bathed with serum, which 
has a reddish or a yellowish-red appearance. The brain in the 
immediate vicinity of the cavity is sometimes softened. Eilliet 
and Barthez state that they have seen eight cases of cerebral 
hemorrhage of the capillary form ; ten cases in which the hemor- 
rhage was in cavities ; and in two of the eighteen both forms were 
present. In fLve of those in which the form was capillary the 
disease was limited to portions of the brain, while in the remaining 
three the hemorrhagic points w T ere found in nearly every part of 
the brain. 

Apoplectic cavities are seldom seen in the cerebellum, and, 
whether the hemorrhage be capillary or in a cavity, there is, in 
most cases, as previously stated, more or less congestion of the 
vessels of the brain. 

The proportion of cases of cerebral to other forms of hemorrhage 
is believed by some to be greater in the new-born than at any 
other period of life. Yalleix relates four cases of intra-cranial 
Hemorrhage occurring at this age, two of which were cerebral, one 
ventricular, and in the other the extravasation was in the cavity of 



324: CEREBRAL HEMORRHAGE. 

the arachnoid. Mignot has published eight cases occurring in the 
new-born, in two of which the hemorrhage was in cavities in the 
cerebrum ; in three, in the lateral ventricles ; and in three, external 
to the brain. If the same proportion be observed in other statistics, 
one in three of the cases of intra-cranial hemorrhage occurring in 
the new-born is cerebral. 

Symptoms. — The symptoms in intra-cranial hemorrhage are not 
uniform ; they vary according to the seat as well as the quantity of 
the effused blood. In some cases the extravasation occurs without 
such symptoms as would direct attention to the brain. When the 
hemorrhage occurs at the time of birth, in consequence of the 
strong and long-continued labor-pains, the infant is often born 
apparently dead. This is due partly to the hemorrhage, partly to 
the great congestion of the brain which precedes and accompanies 
the hemorrhage. Resuscitation is gradual and difficult. The in- 
fant's features are livid and perhaps swollen, its respiration is gasp- 
ing, and both pulse and respiration are slow. Its cry is feeble, 
with but slight movement of the facial muscles, and the lungs are 
but partially inflated; the eyelids are closed, and the limbs almost 
motionless. By artificial respiration and by friction, the pulse and 
breathing may be rendered more frequent, but the latter remains 
irregular and gasping. Finally, the limbs grow cold, the surface, 
from a state of lividity, becomes pallid, and death occurs in pro- 
found coma. M. Cruveilhier made many observations at the 
" Maternity" in reference to the death of new-born infants, and he 
believes that one-third of those who die in birth, at the full period, 
die of apoplexy. I have made post-mortem examinations in a few 
cases, when death had occurred from this cause, and in all the 
hemorrhage was meningeal. One of these was born on the 30th 
of December, 1864. The birth was delayed by unusual projection 
of the promontory of the sacrum, so that finally the application of 
forceps was necessary. The infant was apparently stillborn, but 
by persistent efforts on the part of the physician who assisted, it- 
was resuscitated so as to live several hours, though with constant 
embarrassment of respiration and with lividity. At the autopsy 
a large extravasation of blood was found in the cavity of the 
arachnoid, over a considerable part of the convexity of the brain, 
and the substance of the brain was deeply congested. 

Apoplexy in the new-born does not always terminate fatally, or, 
when fatal, in the sudden manner which I have described. Yalleix 
relates the case of an infant who died of pneumonia at the age of 
three and a half months. Its birth had been protracted and diffi- 



SYMPTOMS. 325 

cult, but was completed without the use of instruments. It had 
had during its entire life paralysis of the right side. At the 
autopsy a clot was found near the base of the right thalamus 
opticus, evidently existing from birth. Around the clot the brain 
was softened to the depth of some lines, and was of a bluish-red 
color. A very similar case is related by M. Vernois. An infant 
lived forty-nine days with paralysis of the left side, and died of 
pneumonia. At the autopsy a hemorrhagic excavation in the pro- 
cess of cicatrization was found behind the right corpus striatum 
and the thalamus opticus. 

Intra-cranial hemorrhage occurring from accidents of birth is 
generally attended by marked symptoms, such as have been de- 
scribed. But when it occurs subsequently to birth, whether in 
infancy or childhood, the symptoms vary greatly in different cases, 
and are generally obscure. I will briefly state the symptoms which 
have been observed in both the cerebral and meningeal forms of 
this disease. First, the cerebral. Sedillot relates the case of a 
child seven and a half years old, whose bare head had been exposed 
several hours to the sun's rays. Suddenly, after a paroxysm of 
anger, it was seized with great pain, corresponding with the pos- 
terior and inferior fossse of the cranium. It uttered piercing cries, 
and died in a quarter of an hour. A clot was found in the right 
lobe of the cerebellum. Richard Quinn (Rilliet and Barthez). 
gives the history of a boy nine years old, who in playing with a 
hoop suddenly stopped, carried his hands to his head, and fell 
backwards unconscious. Three or four hours afterwards, when 
examined, he was found pale, surface cool, respiration slow and at 
times stertorous, pulse 50 to 60 per minute; the left arm was 
flexed ; the left leg paralyzed ; the right leg and arm convulsed ; 
right pupil strongty dilated, the left contracted. He died seven 
hours after the commencement of the attack, and a large clot was 
found in the centrum ovale on the right side. 

Rilliet and Barthez relate the following case from Campbell. A 
boy with good previous health was suddenly seized about 7 A.M. 
with repeated vomiting, and in an hour and a half with violent 
convulsions ; he rolled his eyes and uttered inarticulate cries ; pulse 
frequent and hard ; pupils contracted ; trunk and lower extremities 
cool. In the afternoon he presented symptoms of compression of 
the brain, such as dilatation of the pupils, frequent and feeble 
pulse. Death occurred in the evening, and a hemorrhagic cavity 
was found occupying the right middle lobe of the cerebrum. 
G-uibert relates a case of extravasation in the superior part of the 



326 CEREBRAL HEMORRHAGE. 

right hemisphere of the brain in a boy fourteen years old. The 
principal symptoms were feebleness of the limbs, inability to walk, 
cephalalgia, involuntary evacuations, fever, grinding the teeth, 
rigors severe and prolonged, lividity, loss of intellectual faculties, 
dilatation of the pupils, insensibility to light, stertorous respiration. 
Death occurred in about an hour. 

Eilliet and Barthez narrate the history of a girl two years old, 
who, after an attack of measles, was taken with convulsions accom- 
panied with fever and prostration. The convulsive movements 
affected especially the eyes and upper extremities ; the right leg 
was immovable ; the left pupil dilated. These symptoms resulted 
from hemorrhage in the corpus striatum and opticus thalamus. 
The same authors relate also the case of a girl, seven years old, who 
died with a large apoplectic cavity in the left thalamus opticus. 
The symptoms were headache, convulsive movements, loss of con- 
sciousness, delirium, vomiting and constipation, convergent stra- 
bismus. These symptoms nearly disappeared, but in a few days 
the headache returned, with strabismus and a slight drawing of 
the face towards the left; on the twenty-seventh day there were 
some convulsive movements of the right eye, with paralysis of the 
arm. Finally contraction of the arms occurred, with acceleration 
of pulse, irregular breathing, dilated pupils, paralysis, and retraction 
of the head, followed by death on the forty-eighth day. 

These cases, and those from Valleix and Vernois, which have 
been related in our remarks on hemorrhage of the new-born, are 
sufficient to show the character of the symptoms in that form of 
cerebral hemorrhage in which the extravasated blood forms a 
cavity in the interior of the brain. 

If the amount of extravasation is large, and the substance of the 
brain is much lacerated and compressed, death may occur almost 
immediately, and, therefore, without symptoms, or before it is 
possible to determine whether or not symptoms are present. If 
the disease is not so speedily fatal, the symptoms, as appears from 
the above cases, are headache, confusion of thought, or even insen- 
sibility, cries, sometimes piercing, cold extremities, pallor, slow 
and perhaps stertorous respiration, convulsive movements followed 
by paralysis, or convulsions affecting one or more limbs, with 
paralysis of others, pupils contracted or dilated, sometimes one 
contracted and the other dilated, strabismus, rolling of eyes, 
vomiting. 

These symptoms have all been observed in different cases, but 
they are not all present in any one case. Those which are gene- 



SYMPTOMS. 327 

rally present, and on which we mainly rely for diagnosis, are 
headache, convulsive movements, paralysis, confusion of thought, 
irregularity in the pupils, and strabismus. 

In the capillary form of cerebral hemorrhage there is usually 
some complication, so that it is not easy to determine how far 
symptoms are due to the hemorrhage, and how far to the coexist- 
ing pathological state. 

There are, indeed, but few published observations of capillary 
hemorrhage in the substance of the brain uncomplicated with 
meningeal hemorrhage, hemorrhage in a cavity, or some other and 
distinct disease, but so far as I have been able to ascertain the 
symptoms referable to this form of extravasation, they are as fol- 
lows: The child is drowsy; fretful when disturbed; it perhaps 
moans. There are sometimes slight convulsive movements and 
partial paralysis. If there is considerable extravasation, the re- 
spiration is irregular and sighing. Death occurs in coma, occa- 
sionally preceded by convulsions. Taupin relates the case of a 
child nine years old, who died with this form of hemorrhage, 
accompanied by softening of the brain. The disease began at 
night, with delirium, agitation, and piercing cries. In the morn- 
ing, the patient lay in bed, drowsy, not complaining of pain, and 
not replying to questions ; pupils dilated, and insensible to light ; 
left eye half open during sleep, and its axis changed ; eyebrows 
contracted ; face pale ; mouth open ; had no convulsions, but tran- 
sient stiffening of the limbs, during which the thumbs were firmly 
compressed by the fingers ; senses unimpaired, but the face drawn 
to the right ; deglutition difficult ; pulse small, irregular, and 
feeble ; respiration 32, sighing. In the evening he had rigidity 
of the limbs and back, and, finally, was taken with general con- 
vulsions, in which he died at eleven o'clock. The hemorrhagic 
points in this case were numerous. A boy five years old, whose 
case is described by Eilliet and Barthez, died of this disease, pneu- 
monia, and white softening of the intestine. During the last five 
days there were cerebral symptoms, the chief of which were 
drowsiness, fretfulness when disturbed, and moaning without ap- 
parent cause. Another child, whose case is described by Eilliet 
and Barthez, died at the age of four years, with cerebral capillary 
hemorrhage, accompanied by yellow softening. Six months before 
death he had general convulsions, followed by spasmodic move- 
ments of the left side. These subsided, but the left side remained 
feeble. 



328 CEEEBKAL HEMORRHAGE. 

Iii meningeal hemorrhage there are often convulsions, general 
or partial, in some patients tonic, in others clonic. "When partial, 
the convulsive movements may only occur in the muscles of the 
face and eyes. With the spasmodic muscular action is a degree of 
drowsiness and irritability. Paralysis, so common in the apoplexy 
of the adult, and not infrequent, as we have seen, in the cerebral 
form of early life, is sometimes, but not ordinarily, present in 
meningeal hemorrhage. Instead of paralysis, there are vomiting, 
some febrile action, thirst, and loss of appetite. The symptoms 
are different, however, according to the exact seat of the hemor- 
rhagic extravasations, and the duration of the disease. If the 
extravasation end in the formation of a cyst, the symptoms are 
those of hydrocephalus. The following condensed history of cases 
which I have selected as typical, will give us a clearer idea of the 
history and course of the various forms of meningeal hemorrhage 
than can be imparted by a narration of symptoms : — 

M. Tonnele relates the case of a child who was taken with faint- 
ness and convulsive movements. On the following day the trunk 
and inferior extremities became rigid ; deglutition was painful ; 
the pupils were largely dilated, immovable; face pale; pulse feeble 
and intermittent. Death occurred the same day. The dura mater 
was distended. A layer of coagulated blood, of great thickness, 
extended over the convexity of each hemisphere. The veins 
ramifying in the superior part of each hemisphere were distended 
with coagulated blood. The hemorrhage was in the meshes of the 
pia mater. Drs. Lombard and Panchard, of Geneva, relate a some- 
what similar case. A child thirteen months old was convalescing 
from inflammation of the bronchial and intestinal mucous surfaces, 
when it was seized with general convulsions ; the mouth and eyes 
were open, and the eyes directed upwards ; pupils contracted ; 
pulse frequent and irregular. The convulsions abated somewhat, 
but soon reappeared with violence. The patient became insensible, 
and died nineteen hours after the commencement of cerebral symp- 
toms. The extravasated blood covered the upper surface of both 
hemispheres. Prom the above cases we see the symptoms and the 
course of meningeal hemorrhage, when the extravasation is so 
large that death speedily results. In protracted cases of meningeal 
hemorrhage, there is either a gradual disappearance of symptoms 
and return to health, or, circumscribed hydrocephalus occurring, the 
symptoms of that disease arise. 

Diagnosis. — It is evident from what has been stated that the 
diagnosis of intra-cranial hemorrhage is attended with unusual 



PROGNOSIS — TREATMENT. 329 

difficulty, since the symptoms of this disease occur also in other 
and distinct pathological states. The history of the case, and 
especially the character of the cause, if ascertained, will aid in 
diagnosis. If there has been an obvious determination of blood 
to the brain, or some known obstruction to the return of blood 
from that organ, the persistence of cerebral symptoms would 
justify us in concluding that either serous or sanguineous effusion 
had supervened on a state of congestion. The points of differential 
diagnosis between apoplexy and meningitis are the sudden and 
full development of symptoms in one case, the gradual commence- 
ment and gradual increase of symptoms in the other ; differences 
also of symptoms in certain respects ; for example, as regards febrile 
reaction, constipation, etc. 

There is one symptom in cerebral hemorrhage which is of great 
diagnostic value, namely, paralysis. Its progress affords strong 
evidence that there is extravasation of blood, and probably in a 
cavity in the substance of the brain. If the extravasation end in 
the formation of a cyst, the symptoms and appearances of hydro- 
cephalus, which, after a time, arise, throw light on the nature of 
the disease. 

Prognosis. — There can be no doubt that many cases of intra- 
cranial hemorrhage occur and terminate favorably without the 
nature of the disease being suspected. In such cases the amount of 
extravasated blood is small or moderate. In several published 
cases in which the accuracy of the diagnosis was shown by post- 
mortem examinations, the patients were convalescing from the 
hemorrhage when they succumbed to intercurrent diseases. If, 
however, the amount of extravasated blood is such as to give rise 
to those symptoms which have been described, the prognosis is un- 
favorable. Recurring convulsions, and persistent stupor from 
which it is difficult to arouse the patient, are unfavorable symp- 
toms. If the convulsions cease, and consciousness returns, even if 
there is paralysis, the result may be favorable. 

Treatment. — The proper treatment in intra-cranial hemorrhage 
depends on the state of the patient, the time which has elapsed 
since the extravasation, and the degree of it, as shown by the 
nature and severity of the symptoms. If, as is often the case, the 
patient is robust, and is visited soon after the commencement of 
the attack, cold applications should be made to the head, mustard 
to the back of the neck and perhaps chest, and derivation should 
be produced by mustard pediluvia. In many cases, especially in 
active congestion, it is advisable to apply leeches to the temples, 



330 CONGENITAL HYDKOCEPH ALUS. 

and the bowels should be opened by a stimulating enema. In 
active congestion, also, prompt purgation by salines or other ca- 
thartics is sometimes of great importance. The object of such 
treatment is to relieve congestion of the cerebral and meningeal 
vessels, and thereby prevent further extravasation of blood. If 
the congestion be active, the pulse continue full and frequent, and 
the face be flushed, it is proper in many cases to control the action 
of the heart by a sedative. For this purpose the tincture of vera- 
trum viride may be given in doses of one drop to a child five years 
old, repeated in three hours if necessary, or aconite may be employed. 
If the stupor or convulsions continue after sufficient time has 
elapsed for the patient to receive the full benefit of the above 
remedies, more active counter-irritation is required. Cantharidal 
collodion should be applied behind each ear. If the hemorrhage 
occur from passive congestion, or in a cachectic state of system, 
active depressing remedies should not be employed. External 
derivatives are of service, as well as cool applications to the head, 
and we should attempt, so far as possible, to remove the cause of 
the congestion and hemorrhage. If it depend on a cachectic state, 
tonic or other remedies calculated to relieve this state are indicated. 
The hemorrhage from such a cause is apt to be in points in the 
substance of the brain, or in moderate quantity over the surface of 
this organ, and by a timely use of constitutional remedies possibly 
we may prevent further extravasation of blood and increase the 
chance of the patient's recovery. 

If a cyst result from the hemorrhagic effusion, the treatment 
which is proper is that described in the chapter on Acquired 
Hydrocephalus. 



CHAPTER VII. 

CONGENITAL HYDROCEPHALUS. 

Congenital hydrocephalus consists in an excess of the cerebro- 
spinal fluid, lying either external to the brain, or more frequently 
in its interior. It is due to some vice in the development of the 
brain or its membranes, or to a pathological state occurring in them 
during intra-uterine life. This disease is ordinarily apparent from 
the symptoms and appearances at birth, but not always. Occasion- 
ally nothing unusual is observed in the shape of the head or aspect 



ANATOMICAL CHARACTERS. 



331 



of the infant till after the lapse of some weeks, when the charac- 
teristic physiognomy begins to appear. In these cases the disease 
is still congenital, as there is every reason to believe that the ab- 
normal state to which the excessive production of fluid is due 
existed from birth. In cases of arrested or partial development of 
the brain, as, for example, when a considerable portion of the 
hemispheres is absent, there is often an unusually large quantity 
of fluid which serves merely as a compensation for the lack of 
brain. I do not regard such cases as examples of hydrocephalic 
disease, since the effect of the fluid is not injurious, but rather 
useful. I restrict the term congenital hydrocephalus to those 
cases in which the brain is complete, or, if incomplete, the quantity 
of fluid is more than suflicient to supply the deficiency. 

Anatomical Characters. — According to M. Breschet, the fluid 
in congenital hydrocephalus may be — 1st, between the dura mater 
and the cranium ; 2d, between the dura mater and the parietal 
arachnoid ; 3d, in the cavity of the arachnoid ; 4th, in the ventri- 
cles; 5th, between the arachnoid and the brain. 

In a large majority of hydrocephalic patients the seat of the 
effusion is the ventricles. As the quantity of fluid increases, the 
pressure from within gradually 
unfolds the convolutions of the 
brain, at the same time produc- 
ing expansion of the cranial arch. 
When the amount of fluid is con- 
siderable, and it becomes so in 
the course of a few weeks or 
months, the hemispheres are 
spread out in a thin lamina on 
either side, gradually decreasing 
in thickness from the base of the 
cranium to the vertex, where the 
brain-substance is sometimes so 
thin as to be scarcely perceptible. 
Complete absence of brain in this 
situation, namely, at the vertex, 
even in extreme cases of expansion and flattening of the hemi- 
spheres from the pressure of the liquid is rare, though the brain- 
substance at this point is sometimes almost as thin as either of 
the membranes, so that the wall of the sac is translucent. The 
membranes which surround the brain do not usually undergo any 
alteration, except such as arises from the distension. The falx 




Congenital hydrocephalus. (From Gross.) 



332 CONGENITAL HYDROCEPHALUS. 

cerebri sometimes disappears, and sometimes the meninges present 
a whiter hue from maceration than in health. The distension also 
causes such an expansion of the pia mater that it becomes very 
thin, and in places scarcely visible, but its presence in every point 
can be demonstrated. 

The changes which the cranial bones undergo, both in their 
chemical character and in their shape, in hydrocephalic patients, 
if the amount of fluid is considerable, are interesting and remark- 
able. The base of the cranium undergoes little change, but those 
portions of the frontal, parietal, and occipital bones which con- 
stitute the arch are expanded in all directions, while they become 
much thinner. There is deficiency of lime in their constitution, 
so that their organic elements are greatly in excess. This renders 
them flexible and semi-transparent. Notwithstanding the expan- 
sion of the bones, there are usually interspaces between them, of 
greater or less size, according to the amount of fluid. 

The scalp, being stretched by the pressure within, becomes tense 
and thin, and is scantily covered with hair. The veins which 
ramify in it are unusually prominent and large, and the head is 
elastic on pressure, from the amount of liquid beneath. In the 
common form of congenital hydrocephalus, namely, that in which 
the liquid is in the interior of the brain, the shape of the orbital 
plates of the frontal bone is changed, so that the eyeballs have a 
downward direction. This change in the axis of the eyes occurs 
at an early period, and it continues through the entire disease, 
becoming more and more marked as the quantity of liquid 
increases. If the amount be large, the lower part of the cornea is 
buried under the under eyelid, while the conjunctiva is visible 
between the cornea and the upper eyelid. The persistent down- 
ward direction of the eyes is characteristic of this disease, and, in 
connection with enlargement of the head, is an important diag- 
nostic sign. 

If we examine the interior of the cavity after the fluid is evacu- 
ated, we will find at its base the parts which lie in the floor of the 
lateral ventricles, but changed in appearance in consequence of 
pressure. The cornua are enlarged, and the thalami optici and 
corpora striata are flattened. In the early stages of the disease, 
when the amount of fluid is small, there is probably no absorption 
or destruction of parts in the interior of the brain. The various 
portions of this organ retain nearly their normal relation to each 
other. As the quantity of fluid increases, the foramen of Monro, 



ANATOMICAL CHARACTERS. 333 

which unites the lateral ventricles, becomes enlarged, the septum 
luciclum which separates them disappears, and the two ventricles 
form a common cavity. In most fatal cases we find this single 
large cavity. The surface which surrounds the cavity occasionally 
presents a whitish or semi-opaque appearance, which has led to the 
belief, on the part of some, that at a period antecedent to birth 
there was subacute inflammation of this surface, and hence the 
effusion. 

The bones of the face are ordinarily less developed than in 
healthy children of the same age, so that the disproportion between 
the head and face becomes a marked peculiarity. The shape of the 
forehead and face is nearly triangular. 

The foregoing remarks in reference to the anatomical characters 
of congenital hydrocephalus refer in the main to cases which have 
continued for a considerable time, so that their characteristic 
features are well marked. In very young infants, in whom the 
disease is still recent, similar anatomical characters are present, but 
in less degree. 

Congenital hydrocephalus is often associated with other vices of 
conformation, especially with spina bifida. The two, when coex- 
isting, are only parts of the same disease ; the large quantity of 
cerebro-spinal fluid preventing the spinal canal from closing during 
foetal development. 

The fluid in congenital hydrocephalus consists largely of water, 
in the proportion even of 99 parts in 100. In addition to this 
element, there are traces of albumen, chloride of sodium, phos- 
phate and carbonate of soda, and osmazome. 

I have had an opportunity to witness only one post-mortem 
examination in a case of congenital hydrocephalus in which the 
liquid was exterior to the brain. This case was under observation 
in the children's service of Charity Hospital, in 1866. Full notes 
and measurements of the head were taken, which unfortunately 
were mislaid or lost. The infant had congenital syphilis, and had 
a pallid, strumous appearance. The shape and relative size of the 
head are seen in the accompanying figure, from a photograph. 
While the whole head was enlarged, there was a relative excess 
of development in the part between and above the ears. The 
axis of the eyes was not at all changed, and the vision was good. 
The appearance corresponded so closely with descriptions of 
hypertrophy of the brain, that this was supposed to be the ana- 
tomical state. Antisyphilitic treatment was employed, and the 



334 



CONGENITAL HYDROCEPHALUS 




syphilitic eruptions had nearly disappeared, 
when diarrhoea supervened, followed hy 
death. At the autopsy, a quantity of 
transparent or light straw-colored liquid, 
estimated at six or seven ounces, was found 
exterior to the brain, in the great cavity of 
the arachnoid, lying mostly over the supe- 
rior surface of the organ. There was no 
excess of liquid in the ventricles, and the 
brain, though of good size, was not abnor- 
mally large, nor did it possess the firmness 
which is present in true hypertrophy. 
All cases of congenital hydrocephalus may be embraced in two 
groups, namely, that in which the liquid is in the interior of the 
brain, and that in which it lies exterior to the organ. Liquid 
primarily in the arachnoidean cavity permeates the meshes of the 
pia mater, and lies in part underneath it, or this delicate membrane 
may be ruptured. Four of the groups, therefore, described by 
Breschet, may properly be reduced to one, namely, those groups in 
which the liquid lies under, between, or external to the meninges. 
It is probable that some of the cases which led to Breschet's classi- 
fication were examples of acquired circumscribed hydrocephalus, 
the result of extravasation of blood. In this form of hydrocephalus, 
as is stated elsewhere, an adventitious membrane forms external 
to the liquid, becoming in time thin and delicate, and often bearing 
a close resemblance to the normal membrane (especially the 
arachnoid), for which it is sometimes mistaken. 

Symptoms. — If there is a considerable amount of hydrocephalic 
fluid prior to the birth of the child, so that the head is abnormally 
large, parturition is seriously interfered with. The scalp and 
meninges may become ruptured by the severity of the pains so 
that the fluid escaj^es. If this does not occur, the labor is often 
necessarily instrumental. Whether the liquid is present before 
birth or accumulates subsequently to it, the tendency is to an 
increase of the quantity, and a corresponding enlargement of the 
head. 

The digestive function in this disease is at first well performed. 
The infant nurses readily, and has its evacuations with the regu- 
larity of other children. Not many weeks, however, elapse, in the 
majority of cases, before defective nutrition is apparent. 

While the volume of the head increases, other parts are im- 
perfectly nourished and stunted in their growth. Emaciation is 



SYMPTOMS. 335 

common of the neck, trunk, and limbs, associated with progressive 
feebleness. In the last stages of this disease there is more or less 
vomiting, with constipation. If there was previously the ability 
to support the head, it is now lost, and the erect position is no 
longer possible. In marked cases, when there is great disproportion 
between the head and the rest of the system, there is frequently 
not even the ability to rotate the head on the pillow. As long as 
the cranial bones yield readily to the pressure from within, and 
there is no compression of the brain, the function of this organ is 
not seriously impaired. The child recognizes its mother or nurse, 
and it can be amused like other children, though easily fatigued. 
The state of the senses is different in different cases, and some- 
times at different stages of the same case. The sight and hearing 
in some are perfect, in others impaired ; while in others still they 
are good at first, but gradually become obscured and lost. It is 
said that the sense of smell may be perverted so that agreeable 
odors are unpleasant, and vice versa. Many, reaching the age at 
which children begin to walk, cannot walk, or if they do, it is with 
a tottering, unsteady gait. 

When the liquid increases to that extent, and it usually does 
sooner or later, that the brain begins to be compressed, dangerous 
cerebral symptoms arise. The child becomes drowsy, and takes 
less notice of objects. There are twitching of the limbs and finally 
convulsions. The pupils act feebly or irregularly by light, or one 
is more dilated than the other. Strabismus also occurs. As a fatal 
termination approaches, convulsions occur, partial or general. These 
are soon succeeded by the last stage, that of coma, in which the 
patient expires. 

The following case, which I copy from my note-book, is an 
example of the common form of congenital hydrocephalus. It will 
give an idea of the ordinary course of this disease, and show the 
difficulty which we meet with in its treatment. Female, born 
Nov. 9, 1859, with the aid of forceps. At birth the fontanelles 
were unusually large, the cranial bones separated, and the aspect 
in a marked degree hydrocephalic. She nursed at first, but, the 
mother's milk failing, she was afterwards bottle-fed. At the age of 
four months her head, which had increased faster than her general 
growth, measured from one auditory meatus to the other, over the 
vertex, seventeen inches ; the occipito-frontal circumference, twenty- 
three inches. At this time she manifested considerable intelli- 
gence, being able to distinguish her mother from other persons, 
though the head was so large that it was necessary to support it 



336 CONGENITAL HYDROCEPHALUS. 

constantly on a pillow. From the age of four to six months the 
operation of tapping was performed six times with a small hydro- 
cele trocar, by Prof. Stephen Smith, at a point near the coronal 
suture and from an inch to an inch and a half from the sagittal. 
At each operation an amount of fluid varying from twelve ounces 
to one pint was removed, and the head then covered with strips of 
adhesive plaster, so as to form a complete cap. It was necessary, 
however, within the twelve hours succeeding each operation, to 
loosen the dressing, on account of either the occurrence of convul- 
sions or symptoms premonitory of them. The head, within a week 
subsequently to each operation, regained its former size, and as 
there was no permanent benefit, this treatment was discontinued. 
She finally died of entero-colitis at the age of ten months and five 
days. 

At the autopsy the distance from one auditory meatus to the 
other was twenty and a quarter inches; the occipitofrontal cir- 
cumference, twenty-six and a quarter inches. The anterior fonta- 
nelle measured antero-posteriorly four and three-fourths inches; 
transversely, seven and three-fourths inches. The parietal bones 
were separated from each other to the distance of two or three 
inches, and they measured in length nine and one-half inches. 

On opening the cranial cavity, seven pints, by measurement, of 
transparent fluid escaped, exposing a vast open space, at the bottom 
of which were the parts which constitute the floor of the ventri- 
cles, somewhat changed in shape, and from them, on either side, the 
hemisphere was spread in a lamina, so as to cover the internal sur- 
face of the cranial bones. The laminae near the base of the brain 
measured in thickness from half an inch to one inch, and they 
gradually became thinner on approaching the vertex, at which 
point the brain-substance was exceedingly thin, so as to be scarcely 
demonstrable. 

The brain had its normal vascularity and consistence, and the 
cerebellum, medulla oblongata, the base of the brain, and cranial 
nerves presented their usual appearance. On folding the brain 
together, it had the size, shape, and aspect of this organ in its 
ordinary development. Nothing unusual was observed in the mem- 
branes except their great expansion. The above case corresponds 
in its general features with most cases met in practice. 

Diagnosis. — The ordinary form of congenital hydrocephalus, 
that in which the liquid occupies the interior of the brain, can, in 
most cases, be readily diagnosticated. If there is only a moderate 
amount of liquid, it may be confounded with hypertrophy of the 



PKOGNOSIS — TREATMENT. 337 

brain. In hydrocephalus there is commonly more rapid growth, 
and greater expansion of the head; moreover, the enlargement 
occurs equally on all sides, while in hypertrophy, though all parts 
of the cranial vault are expanded, the enlargement is more at the 
vertex than elsewhere. The sign, however, of greatest diagnostic 
value is the direction of the axis of the eyes. In hypertrophy the 
axis is unchanged, while in this form of hydrocephalus, although 
the amount of liquid may be small, the change of axis occurs which 
is described above. In rachitis the volume of the head is often 
considerably enlarged, due sometimes, in part at least, to a deposit 
of calcareous matter on the exterior of the cranial bones. The 
differential diagnosis is based on the shape of the head, round in 
one, square or with prominences in the other, on palpation, direc- 
tion of the eyes, etc. The smaller the amount of liquid, the greater 
the liability to error of diagnosis ; but if the amount is inconsider- 
able and not increasing, little treatment is required, except hygienic 
and tonic, which is also proper in both hypertrophy and rachitis. 
If the liquid is exterior to the brain, as in the case represented 
on page 334, diagnosis may be difficult, but such cases are infre- 
quent. 

Prognosis. — This is unfavorable. The amount of liquid in 
congenital hydrocephalus, as already stated, commonly increases. 
The most favorable result is no increase, or but slight, in the 
quantity, while the natural growth of the infant continues, and 
thus the disproportion between the head and the rest of the system 
gradually disappears. This result is exceptional. Ordinarily, 
while the quantity of fluid increases, the nutrition of the body 
and limbs is more and more deficient. The patient, if not cut off 
by some intercurrent disease, finally succumbs with cerebral symp- 
toms produced by pressure of the fluid. The majority of those 
affected with congenital hydrocephalus die in infancy, but some 
enter childhood, and occasionally one reaches even adult life. 
Cases of recovery have been reported, but if they were genuine, 
the disease was evidently mild, and the amount of liquid small or 
moderate. 

Treatment. — It is a proper question, in many cases, whether 
anything should be done to relieve the hydrocephalic infant besides 
attending to its general health. The anxiety of parents, however 
hopeless the nature of the case if left to itself, reported recoveries, 
and the fact that we have medicines which in many instances 
diminish the amount of liquid in the internal cavities, incline us 
to the use of therapeutic measures. 
22 



338 ACQUIRED HYDROCEPHALUS. 

We may attempt to diminish the quantity of fluid by the use of 
diuretics. Digitalis, squills, nitrate and acetate of potash, have 
been used. Probably the most efficient diuretic in these cases is 
iodide of potassium. This may be given in doses of one to two 
grains every two hours to an infant of six months. Constipation, 
if present, should be relieved by an occasional purgative. If it is 
tolerated, we may partially prevent the expansion of the head by 
a close-fitting cap. For this purpose strips of adhesive plaster, 
about one-third of an inch in width, should be applied so as to 
cover the entire head. The proper way of applying these is as 
follows : first, one strip from each mastoid process to the outer part 
of the orbit on the opposite side ; secondly, from the back of the 
neck, along the longitudinal sinus, to the root of the nose ; thirdly, 
over the whole head, so that the different strips will cross each 
other at the vertex ; and, lastly, a strip long enough to pass three 
times around the head should be applied, passing above the eye- 
brows, the ears, and below the occipital protuberance. Too tight 
an application should be avoided, as it may give rise to convulsions 
or other cerebral symptoms. If the cap can be tolerated, and the 
general health is good, the prospect is more favorable ; but usually, 
from the increase in the quantity of fluid, it is necessary in a few 
days to remove or loosen the plasters in order to prevent convul- 
sions. If this treatment is not successful, we may finally resort 
to tapping. The mode of performing this operation has already 
been indicated in the case which I have detailed. No appreciable 
good result has followed the use of irritating or sorbefacient appli- 
cations in this disease. Nutritious diet and attention to the 
general health are requisite. 



CHAPTER VIII. 

ACQUIRED HYDROCEPHALUS. 

Hydrocephalus, or dropsy of the brain, may also occur in those 
who at birth are well formed and free from disease. Pathologists 
call this acquired hydrocephalus. It is in nearly all cases the 
result of disease, which is located sometimes within the cranium, 
but often in other parts of the system. 

Causes. — The diseases within the cranium which most frequently 



ANATOMICAL CHARACTEES. 339 

produce serous effusion are the meningeal inflammations, both 
simple and tubercular, tumors or other causes which obstruct the 
venous circulation, and hemorrhagic effusion ending in the forma- 
tion of cysts. Prolonged passive congestion often ends in transu- 
dation of serum through the coats of the capillaries. Therefore, 
all those causes of congestion, except such as have a transient or 
momentary effect, may be regarded as causes of serous effusion. 

Among the diseases external to the cranium which produce 
serous effusion within or upon the brain, may be mentioned retro- 
pharyngeal abscess, tuberculization or inflammation of the bron- 
chial glands, scarlet fever, and certain affections of an exhausting 
nature, especially protracted diarrhceal maladies. In four cases 
which have fallen under my notice, the cause was enlarged tuber- 
cular bronchial glands, which, by pressure on the vense innominatse, 
so retarded the flow of blood from the brain as to cause congestion 
and effusion. The causative relation of these glands to cerebral 
congestion is more fully described in our remarks in reference to 
this disease. 

Dropsy of the brain is the common result of protracted diar- 
rhceal affections in infancy, whether entero-colitis or non-inflamma- 
tory diarrhoea. It is preceded and accompanied by passive conges- 
tion of the cerebral veins and sinuses, due in part to feebleness of 
circulation in consequence of the exhausted state of the patient, 
and in part to the wasting of the brain, which always gives rise 
to more or less passive congestion, unless in young infants, in 
whom the cranial bones become depressed and override each other. 
Dropsy of the brain resulting from scarlet fever, and that pecu- 
liar circumscribed dropsy which results from hemorrhagic effusions, 
are described elsewhere. 

A few cases have been related by different observers, Aber- 
crombie among others, in which dropsy of the brain seemed to be 
essential. Nothing abnormal was observed, with the exception of 
serous effusion. But the reports of such cases are, for the most 
part, meagre ; and, as Barrier has well said, we are not to accept 
such cases as examples of essential dropsy of the brain, unless 
the post-mortem inspection is so complete as to render it certain 
that there was no antecedent disease to which the dropsy was due. 

Anatomical Characters. — Acquired hydrocephalus usually oc- 
curs after the cranial bones are firmly united, and, therefore, the 
shape of the head is not materially altered. If it occur at an early 
age, before there is firm union, there may be expansion of the cra- 
nial arch, as we sometimes observe in the circumscribed hydro- 



340 acquire!) hydrocephalus. 

cephalus resulting from hemorrhage. The effusion in acquired 
hydrocephalus occurs over the surface of the brain, in the sub- 
arachnoid space, or in the lateral ventricles. In the dropsy of 
protracted diarrhoea! maladies, I have rarely failed to find the 
liquid over the whole superior surface of the brain as well as at its 
base. 

The quantity of fluid in this disease is not large. In the 
majority of cases it does not exceed four ounces, and is often much 
less. It is transparent, or it has a slightly yellowish tinge. The 
membranes of the brain sometimes present their normal appear- 
ance, but in other cases they are injected. ' The brain itself, in some 
cases, presents an injected appearance from passive congestion of 
the veins and sinuses ; but, in other cases, when there has been 
more or less compression of the brain, there is no more than the 
ordinary, or even less than the ordinary vascularity, and the con- 
volutions are somewhat flattened. 

Symptoms. — The symptoms of the pathological state, which 
gives rise to the dropsy, precede and accompany those which are 
referable to the dropsy itself. The dropsy declares itself by 
symptoms which are alarming from the first. 

In children old enough to speak, or manifest intelligence, there 
may be at first complaint of headache. The child is irritable, its 
mind confused or wandering at times, or there is actual delirium. 
After a time drowsiness occurs. The head seems too heavy for 
the body, and is buried in the pillow. In fatal cases the features 
become pallid, the pupils sluggish, and perception and conscious- 
ness are gradually lost. The child lies in profound sleep, which 
increases. There are now often convulsive movements, partial or 
general, and these soon end in coma, in which the patient dies. 

Prognosis. — Acquired hydrocephalus commonly ends unfavor- 
ably. The prognosis depends not only on the quantity of liquid, 
but on the nature of the cause. If the cause be venous obstruc- 
tion within the cranium or thorax, as we have no means of remov- 
ing it, death is inevitable. If it be an exhausting disease, as 
entero-colitis or scarlet fever, although the case is not absolutely 
hopeless, the prospect is still unfavorable. It is only favorable 
when the quantity of effused fluid is small, the system not much 
reduced, and the primary disease mild. When acquired hydro- 
cephalus arises from meningeal apoplexy, the case is apt to be 
chronic. The symptoms and termination of this form of the dis- 
ease are very similar to those in congenital hydrocephalus. 



SIMPLE AND TUBERCULAR. 341 

Treatment. — The treatment in acquired hydrocephalus must 
vary somewhat in different cases, according to the nature of the 
disease on which it depends. I shall indicate the treatment, in 
part at least, in the description of these diseases. Occasionally the 
condition of the patient is such that there is little to encourage 
us in the employment of any remedial measures. In vigorous 
children, if acquired hydrocephalus occur in connection with 
symptoms which indicate too active a circulation, moderate 
abstraction of blood from the temples at an early period may be 
useful, but cases requiring such depletory measures are rare. 
These cases require cold applications to the head ; the bowels 
should be opened, and derivatives should be applied to the feet and 
back of the neck. 

If the congestion be of a passive character, as when the circula- 
tion is obstructed by tumors or otherwise, benefit may still be 
derived. from cold applications to the head, and derivatives to other 
parts. In most cases of suspected dropsy of the brain, unless the 
patient is in such a hopeless state that all treatment is obviously 
futile, vesication should be produced behind the ears. I prefer 
cantharidal collodion for this purpose. In addition to this treat- 
ment, diuretics should be employed, unless there is too great pros- 
tration, or the course of the disease is so rapid that no benefit can 
result in consequence of the tardy action of these agents. The 
best diuretics are the acetate of potash and iodide of potassium. 



CHAPTER IX. 

MENINGITIS, SIMPLE AND TUBERCULAR. 

The most interesting and important disease of the cerebro-spinal 
system in early life, is that which is now designated meningitis. 
It is not infrequent. The mortuary statistics of this city show 
that it is the cause of death in from one in twenty-five to one in 
fifty of the entire number of deaths, the proportion varying some- 
what in different years. 

In 1768, the attention of the profession was particularly called 
to this disease, by Dr. "Whytt, of Edinburgh. This observer, and 
the pathologists succeeding him, forming their opinion of menin- 
gitis from its most prominent anatomical character, namely, serous 



342 

effusion, believed it a dropsy. They accordingly designated it 
acute hydrocephalus. During the last thirty years the profession 
have come to regard the disease as inflammatory, and hence the 
name by which it is now known, and which is believed to express 
its true pathological character. 

Sometimes meningitis in children is an idiopathic disease. In 
other instances it occurs to those affected by tuberculosis, and in 
many, if not in all such patients, there are tubercles in or under the 
meninges, which excite the inflammation in the same manner as 
in the lungs they cause pneumonitis or pleuritis. Therefore two 
forms of meningitis are recognized, namely, simple and tubercular. 

I have records of forty-five fatal cases of meningitis, some occur- 
ring in my private practice, and the remainder in institutions of 
this city with which I have been connected. Post-mortem exami- 
nations were made and recorded in thirteen of them. Twenty-five 
were under the age of one year, of which fifteen were apparently 
well when the meningitis commenced, belonging for the most part 
to healthy families ; three were feeble and cachectic, but apparently 
without tubercles ; and five had miliary tubercles in various organs, 
as shown by post-mortem examination. The condition of the 
other two was not recorded. 

Of the twenty who were over the age of one year, the majority, 
namely, thirteen, presented a decidedly cachectic or a strumous 
aspect before the meningitis occurred, and a considerable number 
had symptoms of pulmonary tubercles. These statistics, as far as 
they go, show that simple meningitis predominates under the age 
of one year, and I may add eighteen months, while over that age 
the tubercular form is in excess. 

The belief has prevailed in the profession, that tubercular me- 
ningitis does not occur in young infants. This idea is fallacious, 
although, as has been stated, meningitis under the age of one year 
is more frequently independent of tubercles or the tubercular dia- 
theses than associated with them. Bouchut, speaking in reference 
to tubercular meningitis, says: "Up to this period it was not 
believed that this disease existed in young children, for no mention 
is made of it in the works of Denis and Billard. Still its existence 
at this age is, nevertheless, incontestable. MM. de Blache, 
Gruersant, Billiet and Barthez, and Barrier have observed several 
examples of it, and I have collected six cases of this disease in the 
practice of M. Trousseau. The youngest child was only three 
months old, and the eldest had arrived at the end of his second 



MENINGITIS, SIMPLE AND TUBERCULAR. 343 

year. £To statistics can be based on so small a number of facts ; 
the only value they have consists in their overruling an opinion 
falsely accredited in medical science." I have witnessed the post- 
mortem of fi.Ye cases of tubercular meningitis occurring in chil- 
dren under the age of one year, as is seen from the above statistics, 
and the age of one of these was only four months. In two, perhaps 
I should say three, of the five the presence of tubercles in the 
meninges was not positively demonstrated ; but in all of the five 
cases miliary tubercles were present in the lungs and other organs, 
so that I did not hesitate to consider the meningeal inflammation 
of a tubercular character. 

In patients over the age of eighteen months, although the pro- 
portion of tubercular to simple cases is larger than under this age, 
the excess is not so great, according to my statistics, as the re- 
marks of some observers would lead us to suppose. There can 
be no accurate statistics of tubercular meningitis without careful 
post-mortem examination of the state of the brain and other organs 
in each supposed case, and this examination sometimes shows the 
meningitis to be simple, when the symptoms and physical signs 
had indicated its tubercular character. As an example, may be 
mentioned a case which occurred in the children's service of Charity 
Hospital, in March, 1868. This infant died at the age of twenty 
months, having, had a cough of moderate severity at least three 
weeks before death, and symptoms of meningitis about four days. 
It was considerably wasted, and was supposed to have tuberculosis. 
At the autopsy, no tubercles were found in any part of the body, 
but parts of both lungs were hepatized. A fibrinous deposit, varying 
in thickness, was found over the pons Varolii, the optic commis- 
sure, along the fissures of Sylvius, over the superior surface of the 
anterior half and also upon the posterior lobe of each cerebral 
hemisphere. As a careful examination failed to discover any tuber- 
cles, the meningitis was considered simple. Those who make 
these examinations, failing to find tubercles in the lungs and other 
organs in which they usually occur, should examine the lymphatic 
glands, for cheesy glands may be the cause of the formation of 
tubercles in the meninges while the organs of the trunk remain 
unaffected. The presence of cheesy glands in the absence of vis- 
ceral tubercles, and with granulations upon the meninges, small, 
covered with fibrin, and of a doubtful character, goes far towards 
establishing the tubercular nature of the meningitis. I have met 
with one such case, the bronchial glands being cheesy. 



344- MENINGITIS, SIMPLE AND TUBERCULAR. 

Age. — The following table gives the age in meningitis, simple 
and tubercular, in forty-two cases in my collection: — 



Cases. 


Age. 


1 

2 


2^ weeks. (Autopsy.) 
2 months. 


20 . . . 


From 3 to 12 months. 


10 
5 

4 


" 1 year to 2 years. 
"2 years to 5 " 
Over 5 years. 



42 

Rilliet and Barthez have also published statistics of the age in 
meningitis. Their cases were observed chiefly in hospital practice, 
and the result is somewhat different. 

In thirty-two cases of simple meningitis observed by these 
authors, eight were under the age of one year, six from two years 
to five, and eighteen over the age of five years. In ninety-eight 
cases of tubercular meningitis, there were two under the age of 
one year, fifty-one between the ages of one year and five, thirty- 
eight between the ages of five years and ten, and seven between 
ten and fifteen years. 

Anatomical Characters. — The dura mater in meningeal inflam- 
mation is either not affected, or is affected secondarily. In many 
cases it retains its normal appearance, its internal surface remain- 
ing smooth and polished. In others it is more or less injected, and 
the surface is dim or lustreless. Ordinarily, also, the free surface 
of the visceral arachnoid continues unchanged, but sometimes it 
becomes dry and even cloudy or opaque, especially where it covers 
those parts which are most intensely inflamed. Exudation rarely 
occurs upon this surface, however intense the inflammation. Those 
who have had the most ample opportunities for observation record 
but few cases of it. 

In both forms of meningitis the inflammatory action commences 
in the pia mater, and is usually confined to this membrane. In its 
meshes, or underneath them, the lesions occur which characterize 
this disease. The pia mater is injected over a greater or less extent 
of surface, usually in tubercular meningitis, at the base of the brain 
alone, or at the base of the brain and in less degree along the sides 
of the organ. The inflammation is ordinarily most intense around 
the pons Varolii, in the subarachnoid space, and along the fissures 
of Sylvius. In simple meningitis the inflammation may also be 
at the base, but in other cases it is at the vertex. It is at the 
vertex when the cause is exposure to the sun's rays. In addition 



ANATOMICAL CHARACTERS. 345 

to the augmented vascularity of the pia mater, we find an effusion 
of serum, fibrin, and pus, the quantity and proportion of these 
elements varying greatly in different cases. 

The exudation of fibrin is greatest along the course of the vessels, 
and in the depressions between the convolutions, and the opacity 
is most marked in these situations. Pus, when present, is almost 
semi-solid, from the small proportion of liquor pnris which it 
contains, even in recent cases. If the disease have continued 
several days, the liquor puris may be mostly absorbed, and the pus 
cells becoming shrivelled, irregular, and aggregated, may resemble 
closely the cheesy transformation of tubercle cells. 

The fibrinous exudation presents features of interest. It does 
not usually attain much thickness, but by its opacity it conceals 
from view the brain underneath. If it occur in the fissures of 
Sylvius, the anterior and middle lobes are united by it. It is usu- 
ally infiltrated through the substance of the pia mater. Some- 
times little masses of variable size, often not as large as a pin's head, 
appear at the point of inflammation. These masses are firm, of 
a whitish color, or a light yellow, and their number varies in dif- 
ferent cases. They consist of a firm, homogeneous substance, 
containing granular matter, and cells which often bear a close re- 
semblance to tubercle corpuscles, but are distinct. These corpuscu- 
lar bodies are plastic nuclei or plastic cells, often shrunken. It is , 
seen, then, that there are two morbid products which may be mis- 
taken for tubercle: one, pus which has been in great measure 
deprived of its liquid element; the other, plastic nuclei collected in 
little bodies, so as to resemble the ordinary form of crude tubercle. 
I once carried to one of the best microscopists and pathologists of 
this city some of the exudation from a case of meningitis, the cel- 
lular element in which could not readily be distinguished from 
shrunken tubercle corpuscles. The exudation was from a child 
two years and eight months old, with good health previously to 
the meningitis ; without tubercles in any part of the body, with 
parents healthy, and with no predisposition to tubercular disease. 
This microscopist, not knowing the history of the case, or character 
of the family, and ignorant, like all of us at that time, of the true 
tubercle cell, pronounced the exudation tubercular after a careful 
examination with the microscope. Bouchut says : " The whitish 
miliary granulations which are observed on the surface of the pia 
mater have a certain consistency and tenacity which render them 
difficult to tear with the needles used for the preparation for the 
microscope. These bodies are formed : 1. Of fibro-plastic elements, 



346 MENINGITIS, SIMPLE AND TUBERCULAR. 

whether nuclei or fusiform fibres ; oval-shaped cells are generally 
present, but not always. The nuclei are oval or spherical, gene- 
rally very small — that is to say, they hardly exceed in diameter 
0.008 mm. to 0.009 mm. The presence of these little spherical 
nuclei must be insisted on, because, with a less power than 5.50 dia- 
meters, it would be sometimes impossible to establish the differences 
which separate them from the elements of tubercle ; the fusiform 
fibres are small and rare. 2. There exists a considerable quantity 
of amorphous homogeneous matter, in which minute granulations 
are scattered: it is very dense, and keeps the other elements 
strongly united together, so that it is difficult to isolate them 
completely. 3. Vessels are very rarely observed ; the fibres of cel- 
lular tissue are also rare, or altogether wanting." 

There being two microscopic elements which are distinct from 
tubercular formations, but are liable to be mistaken for them, 
namely, shrivelled pus cells and plastic nuclei, more or less altered, 
it is seen, in part at least, why the older writers, and some of a more 
recent date, either hold that all meningitis is tubercular, or that 
there are comparatively few cases of the simple form. 

On the other hand, there are cases of true tubercular meningitis 
which, even with a pretty careful microscopic examination, might 
be, and probably often have been, regarded as simple. In order to 
a better understanding of this subject, I may be permitted to repeat 
certain facts already stated in the article on tuberculosis. The 
views of pathologists in reference to what is the primary form of 
tubercle, and what is and what is not tubercular matter, have 
recently undergone a great change. It is now believed that the 
tubercle cell is a round, pale, slightly granular cell, identical in 
appearance with the normal cell of the lymphatic glands, being in 
the average somewhat smaller than the white corpuscle of the 
blood ; that it is produced mainly from the nuclei of the connective 
tissue by proliferation; that it is vitalized like other cells, and, 
of course, has functional activity; that the true, the living cell, is 
found only in the so-called gray, semi-transparent tubercle. It is 
furthermore believed, that what has heretofore been considered 
the tubercle cell, namely, the irregular, sometimes angular, some- 
times oval cell — without, indeed, any typical form — may be a dead, 
shrivelled, and altered tubercle cell, or a dead, shrivelled, and 
altered pus or other cell. If, therefore, such cells are found in the 
meshes of the pia mater, we cannot determine from the microscope 
their true character. "We can only form our opinion in reference 
to their nature from concomitant circumstances, or from discover- 



ANATOMICAL CHARACTERS. 347 

mg in connection with them the true tubercle cell. Those 
products which have been designated crude tubercle and tuber- 
cular infiltration, contain these shrivelled cells, or shrivelled 
nuclei; and they may have a tubercular origin, or, on the other 
hand, an inflammatory origin, without either the tubercular 
product or diathesis. 

In the tuberculosis of young children, I have found, in a large 
proportion of cases in which I have had an opportunity to make 
post-mortem examinations, miliary tubercles disseminated through 
the lungs, and perhaps other organs, in small masses, many of 
them not larger than a pin's head, and some occurring as mere 
specks scarcely visible. These minute tubercular formations have 
ordinarily been semi-transparent, and sometimes even transparent 
like minute drops of water, and containing the true and unchanged 
tubercle cell. Now if in such a case meningitis occur, we may 
find the tubercle cell in or with the fibrin at the base of the brain. 
But failure to find it, even with protracted microscopic examina- 
tion, does not prove its absence from this locality, for I consider 
it almost impossible to discover in the midst of the fibrinous 
exudation such minute points of tubercular matter as are seen in 
the lungs, liver, or elsewhere. In view of these facts, I know no 
better rule for the practitioner, who cannot command the time for 
thorough microscopic examinations, than to consider as tubercular 
all cases of meningitis in which tubercles or cheesy glands are 
observed, in whatever part of the system, and consider as examples 
of simple meningitis all those cases in which no tubercles are 
apparent in the meninges or in any other organ of the trunk. 

The pia mater is often firmly adherent to the brain at the seat 
of inflammation, so that on raising it a portion of the brain may 
be detached and removed with it. The extent of the inflammation 
varies much in different cases. There may in extreme cases be 
pretty general inflammation of the pia mater. In cases of such 
extensive meningitis, the symptoms are apt to be severe, and the 
course of the disease rapid. Thus, in the month of April, 1866, a 
girl eleven years of age, in the Protestant Episcopal Orphan 
Asylum of this city, had complained occasionally of dizziness, but 
was otherwise in good health, cheerful, and with excellent appe- 
tite, till Thursday, when she was affected with vertigo, more 
persistent than previously, and with headache. At 2 P. M. on 
the following day she was seized with general convulsions, and 
continued insensible or nearly so, with occasional convulsive 
movements, till Monday, when she died comatose. The pia mater 



348 MENINGITIS, SIMPLE AND TUBERCULAR. 

at the vertex, sides, and base of the brain had a cloudy appearance, 
and underneath it, in places, was a thick creamy substance in 
small quantity, which, examined by the microscope, proved to be 
pus, the largest amount being near the pons Varolii. There was 
no tubercle under the meninges or elsewhere, and no appreciable 
fibrinous exudation. The inflammation in this case was obviously 
intense. The only additional lesions noticed were moderate con- 
gestion of the brain, and an increase in the quantity of the cerebro- 
spinal fluid. 

If the disease is protracted three or four weeks, which is rare, or 
even less time, the exuded substance may undergo further changes, 
such as occur in simple exudations in other parts of the system. 
Thus, on the 30th of April, 1860, we made the post-mortem 
examination of an infant at the Nursery and Child's Hospital, 
who had symptoms of cerebral disease, it was stated, for several 
weeks, but the exact time was not ascertained. Prominent among 
the symptoms referable to the cerebro-spinal system towards the 
close of life were the hydrocephalic cry and rigidity of the neck. 
The appearance at the autopsy was remarkable. The anterior 
half of the brain was completely encased in a deposit which had 
nearly the appearance of lard. It filled the fissures of Sylvius, 
and appeared slightly on the anterior aspect of the cerebellum. 
Examined under the microscope, this substance was found to con- 
tain numerous cells, among which could be distinguished some 
resembling pus cells, but nearly all had undergone more or less 
fatty degeneration. Here and there was seen a large cell contain- 
ing numerous small oil globules, the compound granular cell of 
pathologists. 

The brain itself in meningitis is usually injected. On making 
an incision through it, red points are seen upon the cut surface, 
which indicate the seat of the congested vessels. The inflamma- 
tion rarely extends to the walls of the ventricles, but the choroid 
plexus is injected. In exceptional instances pus or fibrin is found 
in the lateral ventricles. In the infant two and a half weeks old, 
whose case has already been alluded to, about two ounces of 
purulent fluid escaped on opening the left ventricle. A small 
amount of liquid of a similar character was contained in the right 
ventricle. The distension of the lateral ventricles with serum is 
one of the common results of meningitis. This fluid is clear or 
straw-colored, or it is turbid in consequence of being mixed more 
or less with the softened brain-substance. The quantity does 
not exceed two, three, or four ounces, and is often not more than 



CAUSES— PREMONITORY STAGE. 349 

one ounce or an ounce and a half. The distension of the two 
ventricles is ordinarily uniform, as they are united by the foramen 
of Monro, but now and then one ventricle is found more distended 
than the other. If there is considerable effusion, the brain is 
compressed and the convolutions have a flattened appearance, 
unless the cranial bones are still separated so as to yield to the 
pressure. If the sutures and fontanelles are open, the cranial arch 
is expanded, sometimes quite perceptibly to the eye. From the 
same cause the anterior fontanelle, if open, is elevated. The foramen 
of Monro is enlarged according to the amount of effusion, and the 
portions of the brain which separate the ventricles are sometimes 
lacerated. In many cases the cerebral substance surrounding the 
lateral ventricles is softened. The softening is found in all degrees, 
from the least appreciable deviation from the normal consistence 
to a state of diffluence so that the brain presents the appearance 
of cream. Hypotheses have been advanced to explain the cause 
of this change in consistence, which are not entirely satisfactory. 
Whatever the explanation, the fact is attested by all observers, 
though there are exceptional cases. Thus Dr. "West has records of 
the condition of the brain in fifty-nine cases, in thirty-seven of 
which there was considerable softening, and in the remaining 
twenty-two the consistence was normal. 

Causes. — The causes of simple meningitis are not fully ascer- 
tained. Active cerebral congestion frequently occurring, is pro- 
bably a common direct cause. I have known the inflammation 
in at least three instances to occur in infants from four to eight 
months old, who, a month or six weeks previously, had severe 
and protracted attacks of bronchitis. The disappearance of erup- 
tions upon the scalp prior to the commencement of the inflamma- 
tion, is a fact often observed. I have noticed this before the com- 
mencement of simple meningitis, as well as before meningitis, if 
not tubercular, at least occurring in a decidedly scrofulous state 
of system. I have already alluded to a case in which the inflam- 
mation, occurring in the pia mater at the vertex, apparently 
resulted from frequent exposure in the months of August and 
September bareheaded to the sun's rays. 

The cause of tubercular meningitis need not detain us. It is 
sufficiently dwelt upon in the foregoing pages. 

Premonitory Stage. — Meningitis is usually preceded by symp- 
toms which, if rightly interpreted, are of the greatest value. In 
most cases of both the simple and tubercular forms, which I have 
seen, there was a prodromic period, varying from a few days to as 



350 MENINGITIS, SIMPLE AND TUBERCULAR. 

many weeks. The symptoms of this period are obscure, and are 
apt to be mistaken for those of other and distinct affections. 

The child in whom meningitis is approaching, loses his accus- 
tomed vivacity and cheerfulness. He has a melancholy and sub- 
dued appearance, being quiet for a few minutes and then fretful, 
without apparent cause. He can sometimes be amused by his 
playthings or companions for a brief period, when he turns from 
them with evident displeasure. Unexpected and loud noises and 
bright lights are evidently painful. If old enough to describe his 
sensations, he complains of transient dizziness, and at other times 
of headache. His ill-humor, if his wishes are not immediately 
gratified, or if they are denied, is often scarcely endurable on the 
part of friends who are ignorant of the cause. There is great 
difference, however, in different cases, as regards this symptom. 
Some are inclined to be taciturn and quiet, while others are almost 
constantly fretting. The appetite is capricious ; at one time it is 
pretty good, at another it is poor or even entirely lost. The 
patient may take a few mouthfuls of food, or, if an infant, nurse 
for a moment, when his hunger appears satisfied, and he will take 
nothing more. The bowels are regular or inclined to constipa- 
tion. The pulse is natural, or it has times of acceleration, espe- 
cially in the latter part of the day and towards the close of the 
premonitory stage. The duration of this stage is very different 
in different cases. Upon an average it is perhaps about two 
weeks, but it is often longer. In tubercular meningitis the symp- 
toms, both during the inflammation and previously, are apt to be 
complicated by those which arise from tubercles in other parts of 
the system. 

Unless the prodromic period is of short duration, the effect of 
imperfect nutrition is obvious before it closes. The flesh becomes 
soft and flabby, or there is actual emaciation, though generally 
slight. The patient loses his strength, becoming less able to stand 
or to walk, and more easily fatigued. Occasionally, especially in 
the simple form, premonitory symptoms are absent, or are slight 
and of short duration. 

Symptoms. — Dr. Whytt, living in the last century, when the 
tendency was rather to refinement than to simplicity in classifica- 
tion, divided meningitis into three stages, according to the symp- 
toms, especially the pulse. Many subsequent writers, following 
Whytt 's example, have recognized three stages, based not upon 
the anatomical character of the disease, but upon the succession of 
symptoms. Such division of meningitis is in great measure arbi- 



SYMPTOMS. ool 

traiy, since in one case the same symptom occurs at an earlier 
period than in another. 

When the premonitory stage has passed, and inflammation is 
developed, some of the symptoms which were previously present 
remain and are intensified, and other new and more characteristic 
symptoms appear. There are now fewer intervals of apparent 
improvement. The child is quiet, often lying with its eyes shut. 
If aroused, he has a wild expression of the face, and is irritated 
by attempts to engage his attention or amuse him. He rarely 
smiles, or takes his playthings, or he notices them for a moment, 
when he turns away with disgust. During sleep there is often at 
first a placid expression of countenance, hut when aroused he has 
the aspect of real sickness; the eyebrows are sometimes contracted, 
as if from headache ; the features wear a melancholy look, and are 
turned away to avoid the gaze of the observer or to shun the light. 
If the anterior fontanelle is open, it is observed to be prominent 
and pulsating forcibly. If consciousness is not lost, and the patient 
is of sufficient age, he complains of headache, or of pain in some 
part of the body. The tongue is moist, and covered with a light 
fur ; the appetite is lost or poor ; there is seldom much thirst ; 
more or less nausea and constipation are present. As the inflam- 
mation continues, and usually within three or four days from its 
commencement, symptoms arise which dispel all doubts, if there 
were any, as to the nature of the disease. The vital powers are 
now evidently beginning to yield. The surface generally is more 
pallid, and there is the curious phenomenon of the sudden appear- 
ance, and, after some minutes, disappearance, of spots or patches, 
or even streaks or active congestion upon the face, forehead, or the 
ears. These, having a bright red color, contrast strongly with the 
general pallor. Ordinarily they are irregularly circular or oval, 
and from one inch to an inch and a half in diameter. A red spot 
or streak is also produced if the finger is pressed upon the surface 
or drawn forcibly across it. It continues a few minutes and then 
gradually fades. Trousseau calls attention to this fact as a diag- 
nostic sign. 

Another curious phenomenon is the variation in temperature. 
The face and limbs at one time feel quite cool, and after some 
minutes, without any excitement or other appreciable cause, the 
temperature rises, so that the surface is warm to the touch. 

Consciousness, in severe cases, may be lost at an early period. 
On the other hand, I have known it in a case of moderate severity 
to remain, though partially obscured, till within twenty-four or 



352 MENINGITIS, SIMPLE AND TUBERCULAR. 

thirty-six hours of death. The patient will usually open his mouth 
for drinks, which are placed to his lips, when there is no other 
evidence of intelligence, and when sight and hearing are evidently 
lost. 

The loss of the senses constitutes an interesting but melancholy 
feature of the disease. Among the first unequivocal symptoms, 
and frequently the very first, are such as pertain to the eye. This 
organ should he watched from day to day when the diagnosis is 
uncertain. Deviation from its normal state affords evidence of 
meningitis. The pupils are seen to dilate or contract sluggishly 
by variations in the intensity of the light, or they are not of the 
same size with those of another individual to whom the same 
amount of light is admitted. Sometimes the first perceptible devia- 
tion from the normal state is an inequality in the size of the pu- 
pils ; while in others oscillation of the iris is observed. At a later 
stage, not generally till convulsions have occurred, the parallelism 
of the eyes is lost, and in most patients they have an upward direc- 
tion. After effusion has occurred, the pupils are commonly dilated. 
As death approaches, the eyes become bleared, and a puriform se- 
cretion collects in the inner angle of the eye and between the eye- 
lids. This secretion is not abundant, but it is sometimes sufficient 
to unite the lids. The sense of hearing is probably lost as soon, 
or nearly as soon, as that of sight, but the sense of touch continues 
longer. The tongue is covered with a moist fur, unless near the 
close of life, when it is sometimes dry. The appetite is gradually 
lost, but often drinks are taken with apparent relish, even when 
there is no other evidence of consciousness. There are two symp- 
toms pertaining to the digestive system which are rarely absent, 
and which possess great diagnostic value ; one is vomiting, the 
other constipation. In some patients, irritability of stomach begins 
at so early a period that it is really prodromic ; it is rarely absent. 
Barrier collected the records of eighty cases of meningitis, in 
seventy-five of which this symptom was recorded present. It is 
due to the intimate relation existing between the stomach and 
brain, through the ganglionic system of nerves. The vomiting 
occurs without effort, and usually at intervals, for several days. It 
is a sudden ejection of the contents of the stomach, apparently 
without preceding or subsequent nausea. It contrasts, therefore, 
with the vomiting due to an emetic, which is attended by distress- 
ing symptoms. With some it occurs frequently, with others not 
more than two or three times daily. Commencing in the first 
stages of meningitis, or even prior to it, it occurs less often as the 



SYMPTOMS. 353 

drowsiness becomes more profound, and finally ceases. Constipa- 
tion is also present, usually from the commencement of the disease. 
It is one of the most constant and persistent symptoms, continuing 
through the entire sickness, unless relieved by medicine, or unless 
there is a coexisting diarrhceal affection. Often, when diarrhoea 
precedes the meningitis, it ceases the moment the latter commences. 
The constipation in this disease is easily overcome by purgatives. 
Several writers speak of retraction of the abdomen as a sign of 
meningitis. A hollow or sunken appearance of the abdomen, 
according to Golis, aids in distinguishing meningitis from fever. 
The anterior abdominal wall approaches the spine, so that the pul- 
sations of the abdominal aorta are distinctly felt. Rilliet and Bar- 
thez, who have rarely observed this retraction except in cerebral 
diseases, attribute it to the state of the intestines rather than to 
the action of the abdominal muscles. 

The pulse in the first stages of meningitis is accelerated, or it is 
nearly natural during certain hours and afterwards accelerated. 
When the disease has continued a few days, often not more than 
three or four, the pulse undergoes a marked change. It becomes 
slower and at the same time irregular. The irregularity usually 
consists in an intermittence of the pulse after each six or eight 
beats. Sometimes the force of the pulse varies, so that a feeble 
pulsation is succeeded by one of greater volume and strength. The 
decrease in the frequency of the pulse cannot fail to arrest atten- 
tion. From 110 or 120 beats per minute in the first stage of the 
inflammation it often descends to a frequency even less than the 
normal adult pulse. At an advanced period, as death approaches, 
the pulse again becomes accelerated and feeble. 

The change in respiration is as decided as that of the pulse. In 
the beginning of the meningitis respiration is sometimes mode- 
rately accelerated, but in other cases it is natural. When the 
disease has continued a few days, the time usually varying from 
three or four to more than a week, a marked alteration occurs in 
the respiratory movements. Their rhythm, like that of the pulse, 
is disturbed. The breathing is irregular, intermittent, and accom- 
panied by sighs. This change in pulse and respiration corresponds 
with the loss of consciousness, and shows that the brain is becoming 
seriously involved. 

When the pulse and respiration undergo the changes which have 

been described, another prominent and grave cerebral symptom is 

often present, namely, convulsions. Its occurrence diminishes 

greatly the prospect of a favorable issue. The severity and extent 

23 



354 MENINGITIS, SIMPLE AND TUBERCULAR. 

of the convulsive movements vary in different cases. They may 
be partial or general. Their duration is often brief, but they 
recur three or four times through the day. They are preceded by 
cephalalgia in those old enough to express their sensations, and 
often by drowsiness. Each convulsive attack ends in still greater 
drowsiness. 

With this group of symptoms another should be mentioned. I 
refer to the hydrocephalic cry. At intervals the patient, without 
being disturbed, and without any change in symptoms, utters a 
scream or sharp cry, and immediately relapses into his former 
state. This cry is more common in the first stages of the disease 
than subsequently, and in some it is absent or is not a marked 
symptom. The glandular system participates in the general loss 
or derangement of function. Tears are seldom shed, even when 
the child is much irritated, and the urinary secretion is greatly 
diminished. The small amount of urine passed sustains an im- 
portant relation to the progress of the disease and the therapeutics. 

The patient usually lingers several days after the pulse and 
respiration are changed in the manner stated. The drowsiness 
becomes more profound, the vomiting ceases, as well as the con- 
vulsive attacks, and sensation and consciousness are entirely lost. 
But even in this state, if nutriment and stimulants are adminis- 
tered with regularity, the child often lives several days longer 
than the friends believed to be possible. At length increasing 
feebleness and rapidity of pulse and coldness of the face and limbs 
indicate the near approach of death, which occurs in a state of 
coma. 

The symptoms described above are such as occur in ordinary 
cases of meningitis, and in the order which I have indicated. But 
he will be disappointed who expects that the above description 
w r ill apply to all cases. 

Meningitis may be so violent and rapid that both the charac- 
ter and succession of symptoms are different from those which 
have been stated. Thus, I have related the case of a girl, who, 
with no prodromic symptoms excepting occasional dizziness and 
slight headache, was taken sick on Thursday, had convulsions on 
Friday, and from this time continued either in convulsions or 
coma till her death on Monday. Again, even in cases of the usual 
duration and anatomical character, some of the most prominent 
symptoms upon which we rely for diagnosis may be lacking. The 
following was a case of this kind: — 



SYMPTOMS. 355 

Case. — On the 5th of April, 1862, 1 was asked to see a bo} 7 two years and 
eight months old, of healthy parentage, and who, during the preceding 
year, had been in uniform good health, but previously had had two or 
three severe attacks of sickness. His head was of large size, and when- 
ever much indisposed he usually had symptoms premonitory of convul- 
sions, which were always, however, prevented. 

One night, in the latter part of March, his parents noticed that his 
sleep was restless, but on the following day he seemed entirely well, 
and the restlessness at night was attributed to a late and hearty supper. 
On succeeding nights, however, he was restless, and, when questioned, 
complained of pain in the abdomen. In a few days he was observed to 
be drooping in the daytime, and his appetite was not quite so good as 
previously. He had continued in this way about a week when my first 
visit was made. 

The abdominal pain had at this time become more constant, but was 
never severe or accompanied by moaning. When asked where he felt 
sick, he placed his hand upon the epigastrium, pressure upon which was 
sometimes tolerated, but at other times painful. The following symp- 
toms were noted: tongue slightly furred, anorexia, thirst, constipation, 
scantiness of urine, no headache or unusual heat of head in any part 
of his sickness. He vomited at intervals from about the seventh to the 
tenth of April, when the irritability of stomach ceased, and there was 
no return of this symptom. 

About April 7th, the respiration was first observed to be irregular 
and sighing, and the pulse intermittent. These symptoms, so tardily 
developed, were the first which indicated cerebral disease. He now lay 
most of the time in bed, with eyes closed, surface commonly pale, with 
occasional rose-colored spots or patches upon the cheek or forehead. 
The pupils responded to light in the usual manner till near the close of 
life, but bright lights were painful ; the last two or three days of his 
life the left pupil was more dilated than the right. He had no convul- 
sions or any spasmodic movement, and was conscious till within a 
few hours of death; the mother states that there was unequivocal 
evidence of his recognition of her on the last clay of his life. He died 
April 17th, nearly three weeks after the commencement of the disease, 
and ten days after the commencement of symptoms which were dis- 
tinctly referable to the cerebro-spinal system. 

Autopsy. — Abdominal organs healthy, though epigastric pain had been 
so constant and prominent a symptom; brain and its membranes some- 
what injected. The meninges covering the base of the brain from the 
most prominent part of the pons Yarolii to the first pair of nerves pre- 
sented evidences of inflammation. There was such opacity of the pia 
mater in places, as to conceal the brain from view. The anterior and 
middle lobes of each hemisphere were glued together by fibrinous 
exudation, and on the left side, along the fissure of Sylvius, was a thick 
deposit of the same character. The lateral ventricles contained about 
an ounce of clear serum, and about half an ounce escaped from the base 
of the brain. The foramen of Monro was considerably enlarged, and 
the brain-substance surrounding the lateral ventricles was, perhaps, 
somewhat softened, but not in a notable degree. 

In this case it is seen that the prominent symptom, and, indeed, 
almost the only marked symptom in the first stages of the disease, 
was pain in the abdomen, and yet the abdominal organs were 



356 MENINGITIS, SIMPLE AND TUBERCULAR. 

healthy. At the very moment when it was highly important that 
a correct diagnosis should he made, the evidences of cerebral dis- 
ease were lacking. This case is, therefore, interesting on account 
of the variation in symptoms from those in the usual form of 
meningitis. There were no convulsions, and consciousness was 
retained as well as vision till near the close of life, and yet the 
lesions were such as are commonly present in meningeal inflamma- 
tion. In such cases a wrong diagnosis is apt to be made, to the 
injury of the patient and the reputation of the physician. 

Occasionally meningitis may continue so long as to almost justify 
its being called chronic, even when there is a large amount of 
exudation upon the pia mater. In meningitis which terminates 
favorably, there is a gradual subsidence of symptoms. I shall 
describe more fully this termination in speaking of prognosis. 

Diagnosis. — It is of the utmost importance to diagnosticate 
meningitis in its first stages, since treatment, to be successful, must 
be commenced early. Some writers describe at length the means 
of diagnosticating the simple from the tubercular form of the 
disease. Differential diagnosis is often difficult, and sometimes 
impossible; but it matters little, practically, whether the form of 
the disease is ascertained. On the other hand, it is very important, 
in order that. the treatment be appropriate, to diagnosticate the 
premonitory or initial stage of meningitis from certain other 
affections not located within the cranium. Sometimes remittent 
or continued fever, or constitutional disturbances arising from 
irritation in the digestive system, simulate closely incipient me- 
ningeal disease, so that the greatest care and discrimination are 
required in order to make a correct diagnosis. Within a compara- 
tively recent period I have known, in three different instances, 
experienced physicians of this city mistake commencing meningitis 
for fevers, not aware of the serious error they had made till the 
inflammation had reached a stage from which recovery was impos- 
sible. In order to make a correct diagnosis in the premonitory or 
initial stage of meningitis, the physician should take time to 
observe the physiognomy, and note every symptom. More than 
one protracted visit is often required to remove all doubt as to the 
exact pathological state. 

Meningitis is usually preceded and in its commencement accom- 
panied by greater restlessness, fretfulness, intolerance of light, 
and greater variation of symptoms than most other diseases. One 
familiar with the physiognomy of infancy and childhood, will 
/discover in the features indication of greater suffering, of more 



PROGNOSIS. 357 

serious sickness, than is commonly present in other and distinct 
affections whose symptoms are similar. 

Sometimes the sudden disappearance of a chronic eruption upon 
the scalp will aid in the diagnosis. This is a sign of importance, 
taken in connection with the symptoms. Headache and vomiting, 
symptoms of early occurrence, should especially arrest attention, 
or, in absence of headache, pain of a neuralgic character in some 
other part. If there is doubt at first, careful and repeated exami- 
nations, if we are familiar with the various signs and symptoms of 
meningitis, will soon remove all uncertainty. When the eyes 
become affected, the respiration and circulation irregular, and 
especially when convulsive attacks begin, diagnosis is easy. In 
fact, an incorrect diagnosis would then be unpardonable; but, 
unfortunately, if proper treatment has not been commenced till 
this period, it will be of little service. 

Prognosis. — Meningitis is one of the most fatal diseases of early 
life. Whether the form is simple or tubercular, if the initial stage 
has passed without proper treatment, death may be considered 
inevitable. Tubercular meningitis, however early recognized, is 
rarely amenable to treatment. M. Guersant {Die. Med., t. xix. p. 
403) believes that recovery from the first stage of tubercular 
meningitis is possible. "In the second stage," says he, "I have 
not seen one child recover out of a hundred, and even those who 
seemed to have recovered have either sunk afterwards under a 
return of the same disease in its acute form, or have died of 
phthisis. As to patients in whom the disease has reached its third 
stage, I have never seen them improve even for a moment." The 
very few reported cases which resulted favorably may have been, 
as M. Guersant has intimated in the context, cases of the simple 
form. Rilliet and Barthez believe that in a few instances tuber- 
cular meningitis has been cured in its first stages, but they state 
also that the disease is apt to return. 

The prognosis in simple meningitis is not so unfavorable, pro- 
vided treatment is commenced at a sufficiently early period. It 
is now generally admitted that the simple form may not infre- 
quently be averted, when threatening, and even arrested in its 
incipiency. In many such cases we cannot, from the nature of the 
disease, be certain that the diagnosis is correct. But when we see 
children relieved, who present precisely those premonitory and even 
initial symptoms which occur in meningitis, we must believe that 
at least some of them would have had the genuine disease if not 
relieved by the measures employed. That recovery is possible from 



858 MENINGITIS, SIMPLE AND TUBERCULAR. 

simple meningitis in its commencement, is also obvious from the 
fact that a few recover even from the advanced stage, when there 
can be no error of diagnosis. 

I have known but two recoveries from meningitis when it had 
continued so long and had reached that degree that the function 
of the brain and cranial nerves was impaired. One of these re- 
covered with the permanent loss of sight, the other with the loss 
of hearing. Both seem to have ordinary intelligence. Another 
case has been communicated to me, in which the patient, a little 
girl, recovered completely, but for several months after the attack 
seemed nearly idiotic. 

Sometimes even in the second stage of meningitis, treatment 
properly employed is attended by amelioration of symptoms. 
Though such improvement may serve to encourage physician and 
friends, it should not be the basis of a favorable prognosis unless 
it continue three or four days. 

Apparent improvement during a few hours or a considerable 
part of a day is not unusual in those who finally die. Thus, in 
an infant whose bowels were previously confined, I have known 
the pulse and respiration to become more regular and the symp- 
toms generally improve, though only for a brief period, by the 
action of a purgative. Dr. Watson says of the advanced stages 
of this disease, it is " often attended with remissions, sometimes 
sudden, and sometimes gradual, deceitful appearances of conva- 
lescence. The child regains the use of its senses, recognizes those 
about him again, appears to his anxious parents to be recovering, 
but in a day or two it relapses into a state of deeper coma than 
before. And these fallacious symptoms of improvement may occur 
more than once." 

Most fatal cases of meningitis terminate between the third or 
fourth and the twentieth clay, the duration varying according to 
the extent and intensity of the inflammation, and the vigor and 
age of the patient. But there are cases in which it may continue 
much longer. It is surprising sometimes how long the patient 
lives, when the symptoms are such that death seems impending. 
Sensation and consciousness may be extinguished, convulsions occur 
at intervals, and the surface have acquired almost a cadaveric 
aspect, and yet the patient lives on. Rilliet and Barthez say, 
" Often have we inscribed upon our notes death imminent, and been 
astonished the next day to find still alive children to whom we 
had scarcely allowed two hours of life." The symptom which I 
have found to be the most reliable prognostic of the near approach 



TREATMENT. 359 

of death, has been a pulse gradually becoming more frequent and 
feeble, though other symptoms remain as before. This change in 
the pulse is usually very apparent during the last twenty-four hours 
of life. 

Treatment. — Such remedial measures should be prescribed during 
the premonitory stage as are calculated to relieve the fretfulness 
or irritability of temper, and quiet the action of the brain, and, 
at the same time, produce a derivative effect from this organ. To 
this end the patient should be kept from all causes of excitement, 
and the bowels should be opened daily, if not naturally, by the use 
of proper medicines. A mustard foot-bath at night and occasion- 
ally through the day is useful, as it produces both a derivative and 
soothing effect. It will commonly produce a few hours' undis- 
turbed rest, while all other measures except, medicine fail. If den- 
tition is taking place and the gums are swollen, it is sometimes pro- 
per to scarify them. This operation, by diminishing the swelling 
and tenderness, may diminish the irritability of system. In most 
cases in which there are symptoms threatening meningitis, mode- 
rate counter-irritation behind the ears is required. The fact that 
the disease sometimes follows the recession of cutaneous eruptions 
of the scalp shows the importance of this remedy ; but it is not 
advisable to produce counter-irritation over a large surface, since 
this may increase the restlessness of the child, and aggravate 
rather than relieve the state of the head. "West says: "Another 
inquiry that you may put is, when are you to employ blisters? 
Certainly not at the beginning of the disease, when they would 
increase the general irritation, and do more harm than good. At 
a later period they may be of service, when the excitement is 
about to yield to that stupor which usually precedes the state of 
complete coma. They should then be applied to the nape of the 
neck or to the vertex." Vesication produced at so late a period as 
Dr. West recommends, can produce little effect in arresting the 
disease ; besides, counter-irritation at the vertex or back of the 
neck is too far removed from the seat of the disease. I have never 
known it, when employed in the manner which I shall advise, to 
increase the restlessness. I have many times prescribed vesication — 
sometimes when the symptoms passed off and there was restoration 
to health; at other times, when meningitis supervened with its 
usual result — and I have never regretted the prescription. Cantha- 
ridal collodion applied with a brush answers the purpose, and from 
the convenience of its application is to be preferred. It does not vesi- 
cate deeply, or produce a troublesome sore. If symptoms indicating. 



360 

the approach of meningitis continue, iodide of potassium should be 
given in decided doses. "We will speak more of this in our re- 
marks on the treatment of the disease. 

Many children who are threatened with meningitis are scrofulous. 
They have already shown symptoms of tubercular disease. They 
are, perhaps, to a certain extent, emaciated, and may have been 
affected with a cough. The premonitory symptoms in these chil- 
dren indicate the approach of the tubercular form of meningitis, 
and a more sustaining course of treatment is required than in those 
who are robust. To such children cod-liver oil may be profitably 
given, three times daily, together with the syrup of the iodide of 
iron, or iodide of potassium. They should also be taken into the 
open air, with proper precautions, and every hygienic measure 
should be employed which will be likely to invigorate the system 
without exciting the brain. 

Loss of blood is not, in general, required during the prodromic 
period nor in the disease. Those of a strumous cachexia, or those, 
whether strumous or not, who are under the age of two years, do 
not, unless in very rare instances, require depletion by leeches, 
much less by venesection. There is one class of patients in whom 
the early loss of blood may, doubtless, be of service, namely, those 
who in a state of robust health are suddenly seized with the in- 
flammation. Leeches should then be applied to the head of the 
patient, if he is seen at an early period. 

The propriety of using opium to allay irritability of system in 
those threatened with meningitis is viewed differently by physi- 
cians. Bouchut says : " Opiates have the inconvenience of increas- 
ing constipation, but they are very useful in calming the state of 
cerebral excitement of young infants. Laudanum should be given 
in a draught in a narcotic dose, at short intervals, gradually in- 
creasing the dose of it until sleep is obtained." I prefer, in order 
to relieve the restlessness, the use of hydrate of chloral. From 
one to three, or even five, grains may be given, and, if necessary, 
repeated after some hours. 

Often, notwithstanding the measures employed, the patient grows 
worse, the symptoms become more continuous, others more alarm- 
ing arise, and meningitis declares itself. For internal treatment, 
there are two medicines which are extensively used by the pro- 
fession — in fact, to the exclusion of nearly all others — the one calo- 
mel, the other iodide of potassium. Those who employ the iodide 
as the main remedy, commonly also prescribe single doses of calo- 
mel occasionally, as an eligible purgative when there is const! pa- 



TREATMENT. 361 

tion, so that half a dozen or more doses may be given in the course 
of the disease. By those who depend upon calomel as the main 
remedy, it is given not only to keep up a relaxed state of the bowels, 
but also in the belief that it arrests the exudation from the menin- 
ges. These last give it daily in small doses. 

My observations have not been favorable to the use of calomel, 
except as an occasional purgative. When administered daily, it 
has a very depressing effect, and it is to be recollected that this is 
a disease in which the vital powers rapidly sink in consequence 
of the loss of appetite and the frequent vomiting. In tubercular 
meningitis, it is obvious that any remedy which greatly reduces 
the strength may promote the formation of tubercles, and thereby 
diminish the chances of recovery. Cases have occurred in which 
calomel was given at short intervals for several successive days, 
and though the meningitis seemed to be relieved, death resulted 
from sheer exhaustion or from some intercurrent affection, the 
result of exhaustion, or of the remedy. In one case related to me, 
fatal gangrene of the mouth, the result of the mercurial treatment, 
supervened after the meningitis had apparently subsided. Unless, 
therefore, statistics show that a larger proportion recover by the 
use of calomel than by iodide of potassium, we should prefer the 
safer agent. Now, while certain patients recover who exhibit 
symptoms which are premonitory of meningitis, and a few from 
meningitis itself, by the use of iodide of potassium, restoration to 
health by the calomel treatment is certainly very rare, if there 
are unequivocal evidences of meningeal inflammation. Dr. "Whytt, 
who lived in the time when calomel and loss of blood were com- 
monly prescribed not only in this but in other diseases, never saw 
a favorable case. Moreover, physicians of the present time incline 
more and more to the use of iodide of potassium, and the rejection 
of calomel, as the main remedy. 

The iodide of potassium should be given early in the premonitory 
period. If, by a careful examination, the absence of any other 
local disease or of a constitutional affection which might give rise to 
similar symptoms is ascertained, this agent should immediately be 
prescribed. The symptoms at this early period are often so obscure 
that a positive diagnosis cannot be made ; but it is better to give 
the iodide even if the diagnosis is wrong, and no meningeal disease 
is threatening, than to err on the other side and withhold its use 
in the prodromic and initial period of the true disease. An infant 
from six to twelve months old should take two grains every two 
hours, and older children a proportionate dose. Larger doses may 



362 

in some cases be administered. "When thus given, the iodide soon 
produces an impression on the system, and especially on the renal 
secretion, the quantity of urine, previously scanty, being largely 
increased. If with the regular and continued use of potassium 
there is no improvement, the case is without remedy. 

Throughout the disease, as well as in its commencement, the 
iodide of potassium should, therefore, be employed until it is obvi- 
ous that there is no chance whatever of improvement, when medi- 
cation may properly be discontinued. The best remedy for the 
convulsions which sooner or later occur in most cases, is hydrate of 
chloral given in small doses. The apartment should be dark and 
quiet ; a moderate degree of vesication should be produced behind 
the ears, and the head be kept cool. In simple meningitis occur- 
ring in children three or four years of age or older, previously 
healthy and robust, it is proper to place a bladder with pounded 
ice over the head, separated perhaps by two or three thicknesses of 
muslin, provided that the temperature is elevated, as it ordinarily 
is. If there is not much heat, or if the child is considerably pros- 
trated, a cloth wrung out of cool water will be sufficient. Bouchut 
recommends irrigation, and condemns the mode of applying cold 
which is recommended above. Says he, " Refrigerants external to 
the cranium are often employed, and their use appears very ra- 
tional ; still they do not possess a very great efficacy. The appli- 
cation of compresses moistened with cold water, ice in a bladder 
and laid on the forehead, are bad remedies, which, by causing too 
considerable alternations of heat and cold, are rather noxious than 
useful to the child. If it is wished to employ refrigerants, recourse 
should be had to continual irrigation. The patient is not to be 
disturbed in its bed; the head should be placed on a cushion, the 
hair being cut very short ; the neck is bound moderately tight by 
an impermeable stuff, so placed on each side as to form a gutter, so 
that the water which has been used in the irrigation can run off 
from each side of the bed without wetting the body of the child. 
Having arranged these, a jar filled with water of a moderate tem- 
perature, 64° Fahr., is placed above the patient ; a siphon with a tap 
is to be placed in the jar, to moderate at will the flow of the liquid. 
To this tap is fastened a skein of loose thread for the purpose of 
conducting the water to the forehead, so as to avoid the continuous 
dropping of the liquid, which would be insupportable." If, how- 
ever, there is an attentive nurse, who renews the wet cloth suffi- 
ciently often, there does not seem to be any danger from reaction, 
as feared by Bouchut. Irrigation requires as constant attention, 



SPURIOUS HYDROCEPHALUS. 363 

in consequence of the restlessness of the child, as does the treat- 
ment by a wet cloth, in order that there be no interruption in 
the employment of it. Few children will remain quiet with a 
descent of water upon the head, except those who have become 
entirely insensible, and in such neither a wet cloth nor irrigation 
affords any material benefit. In simple meningitis in its first 
stages, the diet should be mild and rather scanty; in the tubercular 
form it should be more nourishing; beef-tea and milk-porridge are 
required. In both the simple and tubercular form, at an advanced 
stage, the most nourishing food is required, but stimulants should 
not be given unless near the close of life, when the vital powers are 
failing. 



CHAPTEE X. 

SPUMOUS HYDROCEPHALUS. 

The disease known as spurious hydrocephalus might with more 
propriety be called spurious meningitis. It received its appella- 
tion at the time when meningitis of early life was believed to be 
essentially a hydrocephalus, and was so called. Attention was 
first directed to this affection by London physicians of the last 
generation, particularly Drs. G-ooch, Abercrombie, and Marshall 
Hall, and little can be added to their description of its symptoms. 

Anatomical Characters. — This disease, though resembling me- 
ningitis in certain of its phenomena, is not in its nature inflam- 
matory, nor is it primary. It is the result of some affection often 
chronic, but occasionally acute, which has produced exhaustion, 
especially of the nervous system. When it commences, there is 
usually more or less emaciation, and the symptoms of the primary 
disease are present. To this disease the lesions pertain which are 
found in other organs besides the brain. 

The state of the brain in spurious hydrocephalus is not the same 
in all cases. In some there is no appreciable anatomical alteration 
in this organ. There is no apparent difference, either in the 
meninges or the brain itself, from the condition which we often 
observe in those who have died of diseases which do not affect the 
cerebro-spinal system. In such cases the pathological state is 
simply deficient innervation, or if there is a structural change in 



364 SPURIOUS HYDROCEPHALUS. 

the minute anatomy of the brain, pathologists have not jet 
discovered it. 

The following case, which occurred in the Child's Hospital of 
this city, is an example of this form of spurious hydrocephalus: — 

Case. — A female infant, six months old, died on the 24th day of 
April, 1862, with the following history: It was wet-nursed, fleshy, and 
apparently well, till six da}'S before death, when s} T mptoms of gastro- 
intestinal inflammation w T ere suddenly developed. The vomiting, espe- 
cially, was severe, continuing forty-eight hours. When it ceased, drow- 
siness supervened, and continued till the close of life. The face during 
the four days of stupor was pallid and cool ; eyes partly open, pupils 
sluggish, but of equal size; bowels rather torpid, anterior fontanelle 
depressed. When aroused, the infant noticed objects for a moment, and 
immediately relapsed into sleep; pulse accelerated and not intermittent, 
the day before death numbering one hundred and fifty; respiration 
accelerated, without sighing, numbering on the same day thirty. There 
were no convulsions, and death occurred quietly. The brain weighed 
twenty and a half ounces, and its appearance was perfectly healthy, 
both as regards consistence and vascularity. The amount of cerebro- 
spinal fluid in the ventricles and at the base of the brain was not notably 
increased. The stomach, small and large intestines, were vascular in 
streaks and patches. 

In this case the cerebral symptoms were obviously due to 
exhaustion occurring at an early period, in consequence of the 
severity of the gastro-intestinal affection. 

In a majority of cases, however, of spurious hydrocephalus, 
according to my observation, there is an anatomical alteration in 
the state of the brain and meninges. This consists in passive con- 
gestion of the veins, often with transudation of serum. At the 
same time the cranial sinuses are congested, and are found at the 
post-mortem examination to contain larger and more numerous 
clots than are present in those who die of diseases which do not 
affect the encephalon. Cases might be cited as examples. The 
cause of this congestion and effusion is, in great measure, feeble- 
ness of the circulation due to the general exhaustion of the patient. 
But there is another cause. In protracted diseases, especially those 
of a diarrhceal character, there is more or less wasting of the brain 
as well as of other parts. This naturally, by way of compensation, 
gives rise to congestion of the cerebral veins and to transudation 
of serum. 

The transudation commonly occurs in this disease over the superior 
surface of the brain and in the subarachnoidal space, perhaps also 
more or less in the lateral ventricles. So common is it in the last 
stage of infantile entero-colitis, the summer epidemic of the cities, 
that this stage, which is really spurious hydrocephalus, has been 



SYMPTOMS. 365 

called the stage of effusion. I shall relate m another place 
examples which show the anatomical characters of this intestinal 
disease. 

Symptoms. — Spurious hydrocephalus most frequently results from 
protracted diarrhceal complaints. It may, however, result from 
any disease which is attended by great prostration. As it ordi- 
narily occurs, the patient has for days or weeks been gradually 
losing flesh and strength. Finally drowsiness supervenes, or 
before the drowsiness there is sometimes a stage of irritability. 

Marshall Hall describes two stages of spurious hydrocephalus. 
In the first, he says, "the infant becomes irritable, restless, and 
feverish; the face flushed, the surface hot, and the pulse frequent; 
there is an undue sensitiveness of the nerves of feeling, and the 
little patient starts on being touched, or from any sudden noise; 
there are sighing and moaning during sleep, and screaming; the 
bowels are flatulent and loose, and the evacuations are mucous and 
disordered." The second stage he describes as that of torpor. 
The first stage often, however, does not present those prominent 
symptoms which have been described by Dr. Hall, and this stage 
may even be absent, or not appreciable, especially in young 
infants. 

"Whether or not commencing with the stage of irritability, the 
disease, if not checked, gradually increases. The child soon be- 
comes drowsy. He may be aroused for a moment, but, unless con- 
stantly disturbed, immediately relapses into sleep. He is sometimes 
fretful when aroused, but in other instances is quite indifferent, 
observing without apparent interest objects employed for the pur- 
pose of amusing him. Often there are indications of cerebral pain 
or distress, as contraction of the eyebrows, etc., but many of those 
affected are too young to make known their sensations. Convul- 
sions sometimes occur towards the close of life, but they are not so 
common in this disease as in meningitis. "When they do occur, 
they are generally partial and often slight. The pulse is accelerated 
in most patients prior to and in the commencement of spurious 
hydrocephalus. As the disease advances it becomes irregular and 
intermittent, and towards the close of life it is progressively more 
frequent and feeble. The respiration at first is not much disturbed, 
but at length it becomes irregular, like the pulse. It is feeble and 
accompanied by sighs. Occasionally there is slight cough.- The 
eyelids are partly open, the pupils no longer respond to light, and 
in advanced cases they have a bleared appearance. The diarrhoea, 
which in most instances precedes and causes the disease, continues 



dbb SPURIOUS HYDROCEPHALUS. 

till the stage of stupor arrives, when the evacuations become less 
frequent or cease altogether. In infants the stools are frequently 
green, in older children brown and sometimes slimy. The febrile 
heat of surface, which preceded the disease and was present in its 
commencement, disappears ; the face and hands become cool, the 
features pallid, and the anterior fontanelle, if open, is depressed. 
Death finally occurs in a state of coma, or, if the disease is recog- 
nized and proper remedial measures employed, the result may be 
favorable, even when the symptoms are such that if meningeal 
inflammation were the disease we would consider the case neces- 
sarily fatal. 

The following case is an example of spurious meningitis as we 
often meet it in practice : — 

Case. — On the 13th day of March, 1859, I was asked to see a male 
child twenty-two months old, the records of whose case are as follows: — 

"Was well till about three weeks ago, since which time he has had 
diarrhoea, with febrile symptoms; pulse 162, respiration 52; has a slight 
cough, with a few mucous rales; resonance on percussion of chest good; 
is somewhat emaciated, and appears languid; tongue moist and slightly 
furred. Has all the incisor and three anterior molar teeth, and the gum 
is swollen over the remaining anterior molar and two canine teeth." 

From the 14th to the 18th there was no material alteration in his 
symptoms, with the exception that the diarrhoea was partially restrained 
by Dover's powder in one and a half grain doses. On these five daj^s 
the dejections numbered daily from one to six. The pulse was uniformly 
frequent, varying from 124 to 156, and the respiration on two da3 T s, when 
its frequency was ascertained, numbered 56 and 46. 

"March 19th, pulse 124; has become drowsy since yesterday, and 
when aroused is fretful. Omit Dover's powder. Treatment, cold appli- 
cations to the head, mustard pediluvia. 

"Evening, pulse 136; e}^es constantly closed and head reclining; 
surface generally warm ; tongue dry and furred ; vomited at first, but 
has not in three or four days. Apply cantharidal collodion behind each 
ear, and continue the local treatment. 

" 20th, pulse 130, is constantly sleeping, and when aroused is very 
fretful and soon relapses into sleep; no unnatural heat of head and no 
dejection since yesterday. Treatment, a dose of castor oil, nourishing 
diet. 

"21st, drowsiness as before; cheeks sometimes flushed, sometimes 
pale ; pupils sensitive to light ; margins of eyelids covered with secre- 
tion. The bowels have been opened by the oil." 

On the 22d and 23d there was no material change in the symptoms-. 
He was constantly sleeping, except for a moment when shaken. More 
active stimulation was now employed. Brandy was prescribed, to be 
given every two hours ; beef-tea and milk-porridge frequently. 

On the following day, the 24th, he was more fretful, and less drowsy. 
Brandy and beef-tea were continued. 

On the 25th, with the same treatment, there was still further improve- 
ment ; drowsiness nearly gone and less fretfulness than yesterday ; rolls 



SYMPTOMS. 367 

the head occasionally and does not appear to see distinctly; has a slight 
cough; bowels nearly regular; pulse 100; respiration natural; surface 
warm, and no unnatural heat of head. The same treatment was con- 
tinued, and he rapidly and fully recovered. 

This case is interesting on account of the long duration of 
marked drowsiness, which continued five days, and yet the patient . 
recovered fully in the space of two or three days under the use of 
brandy and beef-tea. 

In May, 1860, 1 was called to treat a very similar case. A child, 
twenty months old, had diarrhoea for two weeks, the stools being 
of a dark-brown color, thin and offensive. He was at first very 
irritable. The pulse was constantly above 130, and the respiration 
was correspondingly increased. The stage of drowsiness finally 
supervened, and for two days he was constantly asleep unless 
aroused by being shaken. During the somnolent stage the pulse 
numbered 140, respiration 36. The face and extremities were cool 
and he finally had a slight convulsion. By stimulants and nutri- 
tious diet he began immediately to improve, and was soon out of 
danger. 

In the following case the result was unfavorable. This case is 
interesting; on account of the anatomical characters of the disease 
as disclosed by the post-mortem examination. It is an example of 
that large class of cases in which spurious hydrocephalus is asso- 
ciated with congestion of the cerebral vessels and serous effusion. 
It is exceptional, however, as regards the long duration of drowsi- 
ness. Ordinarily, protracted diarrhceal maladies which end in con- 
gestion and effusion, terminate fatally in two or three days after 
the drowsy period arrives. 

Case. — " 13th, 1861, called to-day to a German infant eighteen months 
old. It has had diarrhoea four weeks. without regular and proper medi- 
cal attendance; stools from the first brown and thin; during the last 
eight or nine days has been drowsy ; when aroused, opens his eyes and 
is very fretful, but immediately the upper eyelids gradually droop, and, 
unless disturbed, he remains asleep with his eyes partially open ; forehead 
warm, face cool and pallid, and limbs also rather cool; pulse 164, respi- 
ration 32; has had a slight cough about one week, and slight dulness on 
percussion over the left infra-scapular region; depression of infra-mam- 
mary region on inspiration. Treatment : Ammon. carbon at. gr. 1 every 
two hours; nourishing diet. 

" Dec. 20th, has continued drowsy since the last record; pupils mode- 
rately dilated ; a thick secretion between eyelids; right pupil consider- 
ably larger than the left ; vision apparently lost during the three last 
days ; pulse over 140; respiration 44 per minute, accompanied by sighing 
since the 18th; moans much when awake; rolls the head frequently; 
during the last six days the surface back of the ears has been constantly 



368 SPURIOUS HYDROCEPHALUS. 

sore by vesication ; takes the most nutritious diet, with brandy. The 
dejections remain thin and brown, and number three or four daily. 

" From this date the diarrhoea continued, except as it was restrained 
by vegetable astringents. The pulse continued frequent, and a slight 
cough remained. There was on the 21st and 22d partial abatement of 
the drowsiness, but on the 23d it was greater than ever. The body was 
somewhat reduced at the commencement of the cerebral symptoms - , but 
it was now considerably emaciated. The prostration increased daily, 
and the hands were observed to tremble. The face and hands became 
more cold, while the head was warm. On the 24th partial convulsions 
occurred, followed by coma and death. 

u The cerebral veins and sinuses were generally congested, except in 
the anterior portion of the brain, where the appearance was normal. 
Between the brain and its membranous covering, chiefly at the vertex 
and the base, was an effusion of clear serum. The whole amount of 
this fluid was estimated at two ounces. On slicing the brain, the 
puncta were numerous and large, both in the gray and white portions. 
With the exception of the congestion, the substance of the brain pre- 
sented the normal appearance. No inflammatory lesions were present. 
We were not permitted to examine the condition of the intestines." 

Diagnosis. — The only disease with which spurious hydrocephalus 
is liable to he confounded is meningitis. The points of. differential 
diagnosis are the history of the case, especially the antecedent 
diarrhoea or other exhausting ailment, evidence of prostration 
when the cerebral affection commenced, the depression of the ante- 
rior fontanelle in young children, and the cool face and extremities. 

Prognosis. — If the pathological state of the brain is simple ex- 
haustion, the disease can often be arrested by judicious treatment. 
If an incorrect diagnosis be made, and the treatment employed is 
that appropriate for meningitis, the disease which it simulates, 
death is almost inevitable. If transudation of serum has occurred, 
unless slight, the result is apt to be unfavorable, whatever may be 
the treatment. This disease in childhood is more easily managed 
than in infancy, but is less frequent. The prognosis is better in 
the cool months than during the heat of summer. It is more 
favorable if the child is over than if under the age of one year. 
The occurrence of an irregular and intermittent pulse, of respira- 
tion accompanied by sighs, of inequality in the pupils or their 
sluggish movements, with increasing stupor, indicates an unfavor- 
able issue. The cure of the primary disease, with the pulse and 
respiration still natural, or accelerated, without change of rhythm, 
pupils sensitive to light, drowsiness from which the patient is 
easily aroused to a state of entire consciousness, render recovery 
probable, with proper medication and alimentation. 

Treatment. — The indications of treatment are twofold: first, 
to remove the primary pathological state which is the cause of 



ECLAMPSIA. 369 

the cerebral affection; and, secondly, to cure that affection. The 
first is important, since the successful treatment of a disease re- 
quires the removal of the cause. The measures employed for this 
purpose are pointed out in our description of the diarrhceal and 
other maladies which produce spurious hydrocephalus. 

"We may here say that as this disease is due in a very large 
proportion of cases to the exhausting effect of long-continued loose- 
ness of the bowels, astringents and alkalies are required in a 
majority of cases in the stage of irritability, and sometimes also 
opiates. 

Active sustaining measures are indicated. Exhausted nervous 
power, as well as passive cerebral congestion, requires this. The 
diet should be highly nutritious, comprising such substances as 
milk and animal broths, and should be given frequently. Brandy 
is required at short intervals. Dr. G-ooch was in the habit of 
giving the aromatic spirits of ammonia, properly diluted, as a 
quick and active stimulant. Six or eight drops may be given in 
sweetened water to a child one year old, and repeated every hour 
in cases of urgency. If, by proper treatment of the cause, and by 
the use of stimulants and nutritious food, the patient does not 
within a few hours become less stupid and more conscious, there 
is that degree of nervous exhaustion or of serous transudation from 
the engorged cerebral veins which will render death inevitable. 
In some cases it is proper to produce moderate vesication behind 
the ears. 



CHAPTER XI, 

ECLAMPSIA. 



The term eclampsia is used in a more restricted sense by some 
writers than by others. It is used in the following pages to desig- 
nate those convulsive seizures, clonic in their character, sometimes 
general, sometimes partial, which affect the external muscles. 
Eclampsia is therefore synonymous with clonic convulsions. It 
consists in a rapid, forcible, and involuntary muscular contraction, 
alternating with relaxation. It is distinguished from chorea in 
the fact that the latter is a more permanent state, and is charac- 
terized by muscular movements which are partially under the 
control of the will, and are not so violent. 
24 



670 ECLAMPSIA. 

Eclampsia occurs in a great variety of diseases, some of which 
are located in the cerebro-spinal system, some in other parts of the 
body, and some are constitutional. It may also be produced by 
temporary derangements of system, not sufficiently severe to be 
considered disease, and by powerful mental impressions, those of 
an emotional nature affecting the delicate and sensitive nervous 
system of the child. Pathologists recognize three distinct forms 
of eclampsia. The term essential or idiopathic is used when the 
convulsions have no appreciable anatomical character, that is, when 
there is no apparent pathological state in the brain or elsewhere 
which gives rise to the attack. For example, if a child dies in 
convulsions from fright, and all the organs, including the brain, are 
found in their normal state, the eclampsia is called idiopathic or 
essential. If the cause is disease of the brain or spinal cord, it is 
termed symptomatic. If it arises from disease elsewhere, as from 
pneumonia, the term sympathetic is employed. This is in the 
main a good division, but eclampsia may be at the same time 
sympathetic and symptomatic, as when it occurs in consequence 
of congestion of brain, which is induced by severe and frequent 
paroxysms of hooping-cough. 

Causes. — Eclampsia occurs at any period of infancy and child- 
hood, but it is much more rare after the period of six or seven years 
than previously. Some children are more liable to it than others. 
It is produced in one by an agency which in another has no ap- 
preciable effect. There are some, generally those of an impressible 
nervous system, who are seized with convulsions whenever there is 
any slight derangement in the digestive or other organs. Eclampsia 
is frequent in certain families. Thus, Bouchut mentions a family of 
ten persons, all of whom had convulsions in their infancy. One 
of them married, and had ten children, all which, with one excep- 
tion, had convulsions. 

The exciting causes of eclampsia are too numerous to be men- 
tioned in full. It is a symptom in nearly all cerebral diseases. It 
is produced in the nursling by changes in the milk with which it is 
nourished. These changes are usually due to violent emotions of 
the mother, as anger, fright, and grief, to the use of acescent or 
indigestible food, or to derangement, temporary or permanent, in 
her health. Thus, in a case related to me, the catamenia so 
affected the milk that the child was seized with eclampsia at each 
monthly period. In childhood the most common cause of clonic 
convulsions is the presence of some irritant in the primae vise. All 
kinds of fruit, even the mildest, may produce the disease, especially 



PREMONITORY STAGE. 371 

when eaten unripe or taken in undue quantity. I have known an 
infant to be seized with convulsions from eating strawberries, 
which parents usually regard as harmless, and one of the most 
violent and protracted cases of eclampsia which I have witnessed, 
occurred in a child over the age of six years, from swallowing, in 
considerable quantity, the parenchymatous portion of an orange. 
Constipation, worms, dysentery, intussusception, and painful denti- 
tion are also causes which are located in the digestive apparatus. 
Inflammation in some part of the respiratory apparatus is a not 
infrequent cause. Thus eclampsia occurs occasionally in severe 
coryza, in consequence, according to some, of the proximity of the 
inflamed surface to the brain, and the consequent afflux of blood 
to this organ. It is a common complication also of pertussis and 
pneumonia. It occurs often at the commencement of two of the 
eruptive fevers, namely, smallpox and scarlet fever, and in the 
course of the latter disease. 

Violent emotions of the child may also cause eclampsia. Bouchut 
relates the case of a girl, five years old, who was corrected before 
her companions, and was so affected by anger that convulsions 
occurred. Residence in close and overheated apartments, or in 
streets where the air is loaded with offensive vapors and is stilling, 
is a predisposing cause, so that there is a larger proportion of deaths 
from convulsions in the cities than in the country. 

In young children, burns, even when not very severe, are apt to 
terminate suddenly in eclampsia, succeeded by coma and death. 
Urinary calculi, both renal and vesical, frequently produce the 
same result. 

Such are the more common causes of eclampsia. It is seen that 
they are of two kinds, predisposing and exciting. An excitable 
or impressible state of the nervous system constitutes the chief 
predisposition to the disease. Plethora, or its opposite state,, 
ansemia, increases the liability to an attack. 

Premonitory Stage. — In the majority of cases there are pro- 
dromic symptoms, which the experienced and careful physician 
can detect, so as to forewarn friends. The child is perhaps more 
or less drowsy, and, when disturbed, fretful. The eyes often have 
a wild or unnatural appearance ; occasionally they are fixed for a 
moment on an object, and yet apparently without noticing it. The 
sleep is disturbed ; in some there is unusual heat of head, and, if 
old enough, complaint of headache. At times, especially if the 
primary disease is febrile or inflammatory, there is incoherence of 
thought or expression, or even actual delirium. In some children, 



372 ECLAMPSIA. 

when eclampsia is threatening, the thumbs are seen to be carried 
often across the palms. I have observed this especially during 
the convulsive cough of pertussis. A very important prognostic 
symptom is a sudden starting, or twitching of the limbs. This 
shows that the nervous system is profoundly impressed, and but 
slight additional excitation is required to develop eclampsia. This 
sudden starting not infrequently precedes the attack several hours, 
and gives sufficient forewarning. 

The prodromic symptoms are often disregarded by friends who 
do not understand their significance. Even physicians, in the haste 
of their visits, in many instances do not notice them. The symp- 
toms which precede symptomatic and sympathetic eclampsia are, 
moreover, blended with those of the primary affection, and hence 
another reason why they are apt to be overlooked. When the 
convulsions are about to commence, the child generally lies quiet ; 
the eyes are open and fixed. If spoken to or shaken, he takes no 
notice, and does not speak. The direction of the eyes is then 
changed; often they are turned up; sometimes there is strabismus. 
The face may be pale or flushed, and often, especially in cerebral 
diseases, the features present patches or streaks of a flushed appear- 
ance, while around them the natural color is preserved. Immedi- 
ately before the spasmodic movements the child occasionally utters 
a piercing scream, which is probably involuntary, though it seems 
like a supplication for help. The duration of the prodromic stage 
is very different in different cases. It may last from a few minutes 
to several hours, or even more than a day. 

Symptoms. — Eclampsia is general or partial. If general, the mus- 
cles of the face, eyes, eyelids, and of all the limbs, are in a state of 
rapid involuntary contraction, alternating with relaxation. The 
features lose their natural expression, and are distorted ; the mouth 
is drawn out of shape, often to one side, by the violent muscular 
action ; the teeth are pressed together by tonic contraction of the 
masseters, and may be violently struck together, so as to lacerate 
the tougue, if it protrude, or are ground upon each other. Unless 
the attack is of short duration, frothy saliva, perhaps tinged with 
blood from the injured tongue, collects between the lips. The eye- 
lids are usually open, and in severe cases the eyes are turned so 
that the pupils are lost under the upper eyelids, or the muscles of 
the eyes are involved in the spasmodic movements, so that the eye- 
balls are forcibly drawn from side to side. Occasionally, strabismus 
occurs. "While the features are thus distorted, the head is forcibly 
retracted, or is turned to one side; the forearms are alternately 



SYMPTOMS. 373 

pronated and supinated ; the thumbs and fingers are convulsively 
flexed, so that the thumbs lie across the palms, and are covered by 
the lingers ; the great toe is adducted, the other toes flexed ; and 
the toes, as well as legs, participate more or less in the spasmodic 
movements. 

In general convulsions, consciousness is usually lost. The head 
is hot previously to and during the attack — at least in the first 
part of it — and the face flushed. In exceptional cases, especially 
in sympathetic eclampsia, the head is cool and the face pale. The 
pulse is somewhat accelerated, as well as the respiration, and the 
latter is rendered irregular if the respiratory muscles, especially 
those of the larynx, are involved, as they generally are. The 
sphincters are relaxed during the convulsive attack, so that in 
many cases the urine and stools are passed involuntarily. 

Paktial eclampsia is more common than the general form ; it 
occurs in the muscles of the face, including those of the eye, of the 
face, and of one or both upper extremities, or of the face and the 
extremities on one side. The spasmodic movements may be even 
limited to the muscles of the eyes, and they often occur only in 
these muscles and those of the face. Rarely, if ever, does eclampsia 
affect the legs without affecting also the muscles of the arms and 
face. In partial convulsive attacks, sensation and consciousness 
are in some not entirely lost, but in others they are not manifested 
if present. 

The duration of an attack of eclampsia varies in different cases 
from a few minutes to several hours. The average is not more 
than from Rve to fifteen minutes. It does not often continue 
longer than three or four hours in the severest cases. It is some- 
times said to last a much longer time, even for days, but there are 
in these cases intermissions. Violent attacks are usually short. 

When the convulsion ends favorably, the spasmodic movements 
become less and less strong, and finally cease. The child then 
takes a deep inspiration, after which it lies quiet, and the respi- 
ration remains regular or moderately accelerated. Some fully re- 
cover in a few minutes if the eclampsia has been light and the 
cause transient, and seem to experience no inconvenience except 
soreness of the muscles and fatigue. Others soon recover conscious- 
ness, and their temperature, respiration, and circulation become 
natural, but they remain dull for a time, their minds are bewil- 
dered, and they are perhaps unable to speak. In a few hours 
these untoward symptoms pass away. In essential, and in a large 
proportion of cases of sympathetic eclampsia, if properly treated, 



374 ECLAMPSIA. 

and if the cause is recognized and removed, there is no recurrence 
of the convulsion ; with others it is different. In many cases, es- 
pecially of symptomatic eclampsia and of sympathetic, in which the 
cause is grave and persistent, the convulsions return after a varia- 
ble period of a few minutes or a few hours. Six or eight or more 
convulsions may occur within twenty-four hours. Rarely they 
occur several times daily for several consecutive days, but severe 
convulsions, repeated at short intervals for twenty- four or forty- 
eight hours, usually end in fatal congestion of the brain or serous 
effusion. I once attended an infant about six months old, who had 
from four to twelve convulsions daily for eleven days, caused prob- 
ably by a vesical calculus, as there was dysuria, and, at times, 
bloody urine. Some days after the convulsions were controlled, 
while we were deferring exploration of the bladder, death occurred 
suddenly, and the autopsy was not permitted. This case will be 
detailed elsewhere. Bouchut has witnessed a case of hooping- 
cough in which there were daily convulsions for eighteen days. 

In severe eclampsia, the respiration is so embarrassed and cir- 
culation so retarded that congestion of various organs results. 
This passive congestion in the respiratory organs is indicated by 
moist rales in the larynx and bronchial tubes; occurring in the 
brain, it is indicated by profound stupor. It has already been 
stated that death may occur from the cerebral congestion, which, 
continuing, is apt to end in effusion of serum or extravasation of 
blood. In these cases the convulsive movements cease, but there 
is no return of consciousness. The child lies quiet, as if in sleep, 
with pupils not readily acted upon by light, and often somewhat 
dilated ; gradually the limbs grow cool and the pulse feeble, and 
fatal coma supervenes. 

Death does not ordinarily occur from one attack. There are 
several at intervals, during which the stupor is gradually becoming 
more and more profound, till, finally, there is total loss of con- 
sciousness and sensation. This is the most frequent mode of death, 
namely, death from coma. Apnoea may occur in the first attack, 
ending life abruptly and unexpectedly, but in other instances it 
does not result till after several seizures, when, at length, one more 
violent than the others interrupts the respiratory function and 
causes death. 

Occasionally, when life is preserved, there is some permanent ill 
effect of eclampsia. Bouchut says : " The origin of certain perma- 
nent contractions which bring on deviation of the head or of other 
parts, retraction of the limbs, paralysis, etc., must be referred to 



ANATOMICAL CHARACTERS. 375 

the convulsions of the muscles. I have seen several children in 
whom torticollis had no other cause. The drooping of the upper 
eyelid, strabismus, irregularity of the mouth, severe contractions 
of the limbs, often depend on this influence. These accidents are 
consequences of essential as well as of symptomatic convulsions." 

Anatomical Characters. — The morbid anatomy pertaining to 
eclampsia is in most cases twofold : first, the pathological states 
which precede and cause the convulsive movements; secondly, 
those which result from them. We have seen that in sympathetic 
eclampsia the diseases which sustain a causative relation are very 
numerous ; some are constitutional, others local, and the latter may 
have their seat in almost any part of the economy, distinct from 
the cerebro-spinal axis. In some cases of sympathetic eclampsia 
the immediate cause is too active a circulation, a state of hyperemia 
of the cerebral vessels. 

It has already been stated that this hyperemia may be diagnosti- 
cated in young infants in whom the anterior fontanelle is open. Such 
infants, seized with acute inflammation of the mucous surfaces or 
of the lungs, often present a full and rapid pulse and a convex and 
forcibly pulsating fontanelle before the eclampsia begins. In other 
cases of sympathetic eclampsia the primary disease induces passive 
congestion of the brain, and this in turn gives rise to convulsions. 
Eclampsia occurring during the paroxysms of hooping-cough 
affords an example. In the contagious diseases, as smallpox and 
scarlet fever, eclampsia is doubtless often produced by the direct 
action of the specific virus on the cerebro-spinal system. There- 
fore, in a considerable proportion of cases of eclampsia due to 
diseases not located in the cerebro-spinal system — in other words, of 
sympathetic eclampsia — the primary disease induces a pathological 
state of the cerebral vessels or of the blood which circulates 
through them, which state immediately precedes and accompanies 
the convulsions. 

In other cases of sympathetic eclampsia the convulsive move- 
ments are produced by the primary disease, acting directly on the 
nervous system, through the medium of the nerves, without caus- 
ing any appreciable alteration in the state of the cerebro-spinal axis. 
Thus Barrier relates three fatal cases of convulsions occurring in 
pneumonia, in none of which was there anything abnormal in the 
condition of the brain or its membranes. 

The pathological state preceding symptomatic eclampsia differs 
in different cases, since convulsions occur in almost every disease 
of the brain and its membranes. The immediate cause of this form 



376 ECLAMPSIA. 

of eclampsia may be active or passive cerebral congestion, with or 
without effusion ; it may be compression of the brain from various 
causes ; it may be a deficiency as well as excess of the cerebro- 
spinal fluid. 

In essential eclampsia the cause sometimes produces congestion 
of the brain prior to the convulsive seizure. In other cases, as 
when convulsions occur immediately from the effect of anger or 
fright, there is no appreciable change in the state of the nervous 
centres previously to the attack. 

Again, eclampsia, especially when severe and protracted, and 
when occurring in successive attacks, may be the cause of certain 
lesions. It produces congestion of the brain and membranes, and 
perhaps of the spinal cord. Sometimes, if the congestion is great, 
there is also escape of serum from the distended capillaries, and 
the fibrin in the larger vessels, as the sinuses, may coagulate. 

The congestion resulting from eclampsia may give rise to extra- 
vasation of blood and the formation of a clot. If this accident 
occur, there is often paralysis affecting more or less of one side, 
permanent or gradually disappearing. 

It may be difficult to decide whether the cerebral congestion 
precedes the eclampsia or is its result ; but in those cases in which 
it precedes and operates as a cause, it is no doubt increased during 
the convulsive period. The spasmodic muscular action, by render- 
ing respiration irregular and imperfect, also leads to congestion of 
the lungs and sometimes of the abdominal organs. 

Diagnosis. — The only disease for which there is danger of mis- 
taking eclampsia is epilepsy. M. Ozanam mentions the following 
means of distinguishing the two: " Eclampsia differs from epilepsy 
in the frequent occurrence of prodromic symptoms ; the clonic 
form of the convulsions, the rare appearance of froth in the mouth, 
the absence of a hideous livid aspect of the countenance, the spas- 
modic and sobbing character of the respiration, frequency of the 
pulse, and a state of quiet without snoring which succeeds an 
attack." In the young child, however, the above points of dis- 
tinction are not reliable as a means of differential diagnosis. 
Some patients, who seem to have genuine attacks of eclampsia in 
infancy and childhood, prove to be epileptic in subsequent years. 
The usual period of eclampsia is prior to the age of eight years, 
and if convulsions occur after this age without apparent exciting 
cause, or from trifling causes, the disease is probably epilepsy ; if 
prior to the age of eight years, and especially of three or four, they 
are in the vast majority of cases the convulsions of eclampsia. 



PROGNOSIS. 377 

It is often difficult to ascertain the form of eclampsia, whether 
essential, symptomatic, or sympathetic — in other words, to deter- 
mine the cause — till after the convulsions cease. This is especially 
true when, as is frequently the case, the physician is not sum- 
moned till the convulsive movements begin, and it is necessary 
that he should act promptly, with but little knowledge of the 
child's previous history. If there is an obvious antecedent disease, 
as hooping-cough or meningitis, the cause is apparent ; but if the 
previous health has been good, or but slightly disturbed, it may 
be necessary to make more than one visit or examination in order 
to ascertain the seat and character of the cause. In the majority 
of cases of convulsions occurring suddenly in a state of previous 
good health, the cause is seated in the intestines, but sudden and 
unexpected attacks may be due to the commencement of some 
inflammatory affection, as pneumonia, or of a febrile disease, as 
smallpox. Unless the eclampsia is speedily fatal, the physician, 
if he examine carefully, will, in most cases, soon be able to ascer- 
tain the nature of the cause, and diagnosticate the form of the 
disease. 

Prognosis. — Symptomatic eclampsia is always serious. If con- 
vulsions occur in the course of a cerebral disease, it indicates the 
approach of death, but if at the commencement, some recover. 
The recurrence of it, whatever the cerebral disease, is an almost 
certain prognostic of death. 

In idiopathic or essential convulsions the prognosis depends on 
the severity of the attack, and on the age, strength, and previous 
condition of the child. If there are predisposing or co-operating 
causes, as a nervous or excitable temperament, or dentition, the 
prognosis is less favorable than when such causes are absent. 

In sympathetic eclampsia the prognosis varies greatly, according 
to the nature of the primary disease, and often according to the 
stage of that disease. If convulsions occur at the commencement 
of an eruptive fever, they generally subside without untoward 
symptoms, and the fever pursues a favorable course. Eclampsia, 
after the appearance of the eruption, is premonitory of a fatal 
result. I have not yet known a patient with scarlet fever recover 
who had convulsions after the rash had covered the body, and ex- 
perienced physicians of this city tell me that their observations 
correspond with mine. Dr. J. F. Meigs, however, relates one 
favorable case. If the cause of the eclampsia is located in or upon 
the mucous surfaces, a majority recover with judicious treatment. 



378 ECLAMPSIA. 

In convulsions consequent on pneumonia or a burn, more die than 
recover. 

The prognosis in eclampsia is more favorable if tbe parallelism 
of the eyes is retained, the pupils remain sensitive to light, and 
consciousness soon returns. A fatal termination may be predicted, 
if, after the convulsion, the child remains stupid, without any 
evidence of returning consciousness. 

Treatment. — Fortunately, inasmuch as the physician is often 
required to treat eclampsia in ignorance of the cause, the same 
measures are demanded, to a considerable extent, in all cases, 
whether the form be essential, symptomatic, or sympathetic. As 
early as possible in the attack the feet should be placed in hot 
water to which mustard is added, or, if it can be procured with 
little delay, a general warm bath may be used in place. This 
has a soothing effect upon • the nervous system and promotes 
muscular relaxation, while it also produces derivation of blood 
from the cerebro-spinal axis. It is, therefore, useful, especially 
in those cases in which active or passive congestion precedes the 
eclampsia; it is also useful as a preventive of passive congestion 
and consequent oedema of the brain, lungs, and other organs, which 
are the most serious results of eclampsia. It should be continued 
from six to fifteen or twenty minutes, according to the severity 
and duration of the attack ; at the same time cold applications 
should be made to the head, until its temperature, which is 
usually increased, is reduced. The application of a cloth, fre- 
quently wrung out of cold water, is the most convenient and 
ready mode of employing this agent. Cold thus employed acts 
promptly in contracting the vessels of the brain and meninges, 
and diminishing the cerebral congestion. It tends, therefore, to 
remove one of the chief dangers. 

As a large proportion of convulsive attacks originate in the con- 
dition of the bowels, either solely or in part, it is advisable, unless 
there is a previous diarrhoeal affection, to prescribe an aperient. 

The common enema of soap and water will usually produce a 
free and speedy evacuation, and will sometimes disclose the cause 
of the eclampsia in the expulsion of seeds, or other indigestible 
substances or scybala. A cathartic is also often required, especially 
if the enema fail to produce sufficient evacuations. In those that 
are robust, and especially in those beyond the age of two or three 
years, calomel is an excellent purgative, is easily given, and is 
prompt in its action. If the symptoms indicate intestinal inflam- 
mation, the milder purgatives, as castor oil, are preferable, as they 



TREATMENT. 379 

also are in young or feeble children. If the recent ingesta of the 
patient consisted of fruit or of substances of an indigestible 
character, an emetic is appropriate; a teaspoonful of the syrup of 
ipecacuanha, repeated if necessary in fifteen or twenty minutes, 
may be given to a young child, or this syrup in combination with 
hive syrup to one older and more robust. Aside from the ejection 
of the offending substance which it produces, an emetic has some 
effect in controlling the convulsive movements. 

Convulsions sometimes cease, apparently, in consequence of the 
muscular relaxation caused by the emetic. By such measures, 
or even without them, the attack usually termiuates in a short 
time ; but if it continue, and there is considerable heat of head or 
other indication of active congestion of this organ, we may try 
compression of the carotids by the fingers, as recommended by 
Trousseau. This distinguished observer believed that he succeeded 
in diminishing the afflux of blood to the brain, and thereby 
shortening eclampsia, by this simple expedient. Brown-Sequard 
(Keinarks before the United States Medical Association, 1866) has 
stated that this result is due, not so much to compression of the 
carotid, as to pressure on the cervical portion of the sympathetic 
nerve, which (pressure) causes contraction of the cerebral vessels. 

If the convulsions do not cease by the employment of the 
measures recommended above, one or two leeches may be applied 
to the temples if the child is robust, and there is increased heat of 
face or head. The abstraction of blood directly from the head 
has the obvious effect of diminishing cerebral congestion, and 
has been the means of shortening;; the attack and savins; life. 
Antispasmodics have been used for a long period in cases of 
eclampsia, and they are recommended in our standard works. I 
have never observed any benefit from the use in clonic convulsions 
of either assafcetida or valerian ; though I have occasionally ordered 
the use of such agents both by the mouth and by enema. Chloro- 
form, whether inhaled or swallowed, does control the convulsive 
movements. In protracted or frequently recurring eclampsia, 
especially when it is due to a highly sensitive nervous tempera- 
ment, and there is probably little or no cerebral congestion, this 
is one of the most reliable agents employed by inhalation, and it 
is not unsafe if cautiously used by the physician himself. It 
should be employed only in the convulsion, and withheld the 
moment the spasmodic movements cease. In symptomatic eclamp- 
sia, or in the other forms, if there are indications of cerebral 
congestion, I would not recommend its use. Dr. A. P. Merrill 



380 ECLAMPSIA. 

(Amer. Journ. of Med. Set., Oct. 1865) gives chloroform by the 
mouth in the treatment of this disease, and in doses which most 
practitioners would hesitate to prescribe. He has given even a 
teaspoonful at a dose, to a child a few years old, with satisfactory 
result. In most of those cases, however, in which chloroform is 
useful, the hydrate of chloral promises to be a safer and efficient 
substitute, and it is more easily administered. I have already 
spoken of the employment of chloral in the convulsions of menin- 
gitis. 

The propriety of prescribing opium in any form of convulsive 
attacks in children is doubted by many on account of the drowsi- 
ness which it produces. There can be no doubt, however, of the 
propriety and the good effect of its use in certain cases of essential 
and of sympathetic eclampsia. I refer to those cases in which 
attacks of eclampsia occur with intervals during which there is no 
stupor, and the patient preserves consciousness. Opiates may occa- 
sionally be of service in other cases, but in such they are especially 
indicated. Thus, recently, in my practice, an infant six weeks old, 
in whom there was an hereditary predisposition to eclampsia, was 
taken with diarrhoea, and soon after with convulsions. The attack 
was short, but after a brief interval it returned, and during the 
subsequent twelve hours there were about twenty convulsions. 
There was no unusual heat of head or prominence of the anterior 
fontanelle, or other evidence of cerebral congestion. The green and 
unhealthy appearance of the stools showed that the cause was 
located in the intestines. After trial of various remedies, among 
which were antispasmodics, these convulsive seizures were soon 
relieved by the use of paregoric in doses of five drops, which also 
had a salutary effect on the cause of the eclampsia, and in a few 
days there was complete restoration to health. 

In recent times the attention of the profession has been directed 
to the bromide of potassium as a remedy in convulsive disorders. 
It is ordinarily prescribed alone, in powder or solution. I can 
speak favorably of its use in obstinate cases, not only in children 
approaching the age of puberty, but in infants, especially when the 
cause is obscure or beyond our reach. It produces a decided impres- 
sion on the nervous system, so as to diminish the liability to spas- 
modic affections. In the following interesting case, already alluded 
to, this agent was employed with the effect of relieving entirely the 
convulsive seizures, although the cause continued. On the 29th of 
January, 1866, I was asked to see an infant six months old, who, 
during the preceding week, had had an average of eight convulsions 



TEEATMENT. 381 

daily ; each convulsion lasted about eight or ten minutes, and was 
general; the child was nursing, and had no teeth, and no decided 
swelling of the gums. A careful examination could detect no 
cause, though the infant was fretful and seemingly in considerable 
pain. Some days subsequently it was observed to pass, with appa- 
rent pain, urine in less quantity than when in health, and occasion- 
ally tinged with blood. The cause of the eclampsia was therefore 
probably a vesical calculus. Various remedies were made use of 
till February 1st, without diminution in the severity or frequency 
of the attacks ; when bromide of potassium was prescribed in half- 
grain doses every six hours. From February 1st to 3d there were 
two convulsions daily. On the 3d the medicine was given every 
three hours, after which there was no further eclampsia. The 
medicine was discontinued on the 7th. The infant nursed as 
usual, and its health seemed to be re-established, with the excep- 
tion of those symptoms which indicated the presence of a calculus. 
Examination of the bladder for stone was deferred for a few days, 
when, about two weeks subsequently to the last convulsion, the 
infant died suddenly and unexpectedly. Though the result of this 
case was unfavorable, the controlling power of the bromide over 
the eclampsia was apparent. 

Those children who are subject to eclampsia from trifling causes, 
and sometimes without apparent cause, while their general health 
is good, are more benefited by bromide of potassium than by any 
other medicine. The efficacy of the bromide in epilepsy is well 
known, and in all those cases of eclampsia which approximate 
epilepsy, and in which it is feared that the child will become epi- 
leptic, this agent is preferable to all others. It may be given in 
doses of one grain to a child one year old, every three to six hours, 
and an additional half grain or grain for every subsequent year. 

R. Potass, bromid. gr. xvj ; 
Sacch. alb. §ss ; 
Aq. anisi §ij. 
Dose, one teaspoonful every three to six hours, to a child of one year. 

The treatment of eclampsia obviously should vary in different 
cases, according to the cause. If it occur in an eruptive fever, as 
scarlatina, and the eruption has receded, active revulsive mea- 
sures, as hot mustard-baths, are required; if in dysentery, or other 
internal inflammation, sinapisms should be applied over the 
affected part; if the gums are swollen, and the eclampsia is not 
readily controlled by the ordinary measures, they should be 
scarified. In those dangerous cases in which symptoms of cerebral 



382 TETANUS INFANTIUM. 

congestion continue after the eclampsia ceases, additional treat- 
ment is required. The child remains drowsy, does not speak, or 
apparently suffer in any way, and the pupils act less readily 
than in health. If this condition remains after the lapse of a 
few hours, there is probably serous effusion. All attacks of 
eclampsia, unless the mildest, are followed by a period of drowsi- 
ness, but the persistence of it, with symptoms which indicate 
hyperemia, with perhaps effusion within the cranium, calls for the 
employment of additional measures. Yesication should then be 
produced behind the ears, mild revulsives be applied to the extre- 
mities, the head kept cool, the bowels open, and, in certain cases, a 
diuretic like iodide of potassium may be advantageously employed. 
The utmost care should be enjoined in reference to the hygienic 
management of those who are subject to eclampsia. The diet 
should be nutritious, but bland, and all causes of excitement be 
studiously avoided. 



CHAPTER XII. 

TETANUS INFANTIUM. 

Tetanus or trismus is one of the most interesting diseases of 
infancy. It is tirst, in point of time, in the long catalogue of fatal 
maladies. It occurs suddenly and unexpectedly in the robust as well 
as feeble, almost certainly destroying life within a few hours under 
modes of treatment heretofore employed. It is more frequent in 
some localities and conditions of life than in others. In ISTew York 
it is more common than tetanus at any other age, or, indeed, in all 
other ages, since the mortuary statistics of this city exhibit a larger 
number of deaths from this disease in the first year of life than 
subsequently. Infantile tetanus occurs, with very few exceptions, 
in the new-born. 

Interesting and important as is tetanus infantium, it must be 
confessed that our knowledge of it is much more limited and 
imperfect than it should be, when we consider what great advance- 
ment has been made in pathological inquiries during the present 
century. Our information in reference to its causation, symptoms, 
and proper treatment is not much in advance of that of M. Dazille, 
or Dr. Joseph Clarke, who lived in the latter part of the last 
century. 

Did we better understand the pathology of diseases in the new- 
born, or could we more accurately ascertain the condition of 



cases. 383 

organs at this age, doubtless we should occasionally consider those 
phenomena which we now designate as a disease per se, under the 
title tetanus, as symptoms of some other affection. But as tetanic 
rigidity and spasms in the new-born occur so abruptly, masking 
all other symptoms, and ordinarily ending in death without our 
knowing certainly whether or not there is any antecedent disease, 
it seems eminently proper that we should recognize the state in 
which such muscular rigidity occurs with such a rapid result as 
an independent affection. This explanation is required from the 
fact that I have added to the accompanying table one case from 
Billard, which this observer relates under the head of spinal 
meningitis. In this case, an infant three days old was attacked 
with convulsions. "His limbs were rigid and violently bent; the 
muscles of the face were in a continual state of contraction." On 
the following day "the convulsions continued; . . . the body 
remained rigid, and the vertebral column, which the weight of the 
trunk will cause to bend with the greatest ease in a young infant, 
remained straight and immovable whenever the child was raised." 
At the autopsy, in addition to meningeal apoplexy, which is often 
present in those who die of tetanus infantium a thick pellicular 
exudation was found upon the spinal arachnoid. There is, there- 
fore, a strict accordance of the symptoms and history of this case 
with those which other observers describe as examples of tetanus 
infantium ; moreover, as a satisfactory reason for including this 
case in our statistics, certain eminent observers, as we will see, have 
reported epidemics of tetanus in which meningitis was the princi- 
pal lesion. 

Fatal Cases. 

Case 1. Male; taken when three days old; lived sixty hours. Labatt, 
Edin. Med. and Surg. Journ., April, 1819. 
Female ; taken when three days old ; lived forty hours. Ibid. 
Taken when five clays old; lived fifty hours. Ibid. 
Taken when three days old; lived one day. Ibid. 
Male; taken when two days old; lived two days. Billard, 

Treatise on Diseases of Children, Stewart's trans., p. 41*7. 
Male ; taken when three days old ; lived two days. Romberg. 
Male; taken when six days old; lived ninety-three hours. Dr. 
Imlach, Month. Journ. of Med. Sci., Aug. 1850. 

8. Female; taken at five days; lived four da}^. Caleb Woodworth, 
M.D., Boston Med. and Surg. Journ., Dec. 13, 1831. 

9. Negro; taken at seven days; lived twenty-four hours. P. C. 
Gaillard, M.D., South. Journ. of Med. and Phar., Sept. 1846. 

10. Male; taken when seven days old; lived one day. Augustus 
Eberle, M.D., Missouri Med. and Surg. Journ., 1847. 



u 


2. 


a 


3. 


u 


4. 


u 


5. 


u 


6. 


tc 


1. 



384 TETANUS INFANTIUM. 

Taken when seven days old. D. B. Nailer, N. 0. Med. Journ., 

Nov. 1846. 
Male ; taken when three clays old ; lived one day. N. 0. Med. 

and Surg. Journ., Ma} 7 , 1853. 
Negro ; taken when three days old; lived three clays. Robert 

H. Chinn, M.D., N. 0. Med. and Surg. Journ. 
Taken when two days old ; died in four hours after the doctor's 

visit. Ibid. 
Taken when seven days old; lived one day. C. H. Cleaveland, 

New Jersey Med. Rep., April, 1852. 
Negro; taken when seven days old; death finally. Greenville 

Dowell, Amer. Journ. of Med. Sci., Jan. 1863. 
Taken when twelve days old; lived one clay. Thomas C. 

Boswell communicated to Dr. Sims, Amer. Journ. of Med. 

Set., 1846. 
Taken when about five clays old; died at about the age of nine 

days. B. R. Jones. Ibid. 
■Taken at or soon after birth ; lived two days. Dr. Sims, Amer. 

Journ. of Med. Set.. April, 1846. 
Taken at the age of six days ; lived one day. Ibid. 
Taken when three days old; lived two days. Ibid. 
Male; taken at the age of eight days; died in three hours. 

Communicated to the writer. 
Taken at the age of twelve hours; lived two days. Communi- 
cated to the writer. 
Female; taken when seven days old; lived forty-five hours. 

The writer. 
Male ; taken at the age of seven clays ; lived about forty-eight 

hours. Ibid. 
Female ; taken at the age of eight days ; lived three days. 

Ibid. 
Female; taken at the age of five days; lived three da}~s. Ibid. 
Female ; taken when four clays old ; lived two daj- s. Ibid. 
Taken when six da}^s old ; died next da} r . Ibid. 
Taken when five days old ; lived twenty-four hours. Ibid. 
Taken when eight days old; lived two clays. Ibid. 
Male ; taken when five days old ; lived one clay. Ibid. 

Favorable Cases. 

Case 1. Negro; female; taken when three daj^s old; recovered in a few 
days. Robert S. Baily, Charleston Med. Journ. and Rev., 
Nov. 1848. 

" 2. Negro ; taken at eleven days ; recovered in fifteen days. W. 
B. Lindsay, N. 0. Med. Journ., Sept. 1846. 

" 3. Negro; taken when ten days old; recovered in thirty-one days. 
P. C. Gaillard, Charleston Med. Journ. and Rev., Nov. 1853. 

" 4. Male; taken at the age of eight clays ; recovered in twenty-eight 
days. Ibid. 

" 5. Negro; taken at seven days; recovered in fifteen days. Au- 
gustus Eberle, Missouri Med. and Surg. Journ., 1841. 

" 6. Taken when eight days old; recovered in four weeks; Furlong, 
Edin. Med. and Surg. Journ., Jan. 1830. 



Case 11. 


u 


12. 


u 


13. 


a 


14. 


a 


15. 


u 


16. 


u 


11. 


u 


18. 


u 


19. 


u 


20. 


u 


21. 


u 


22. 


a 


23. 


u 


24. 


u 


25. 


u 


26. 


u 


2*7. 


u 


28. 


u 


29. 


a 


30. 


u 


31. 


u 


32. 



FREQUENCY IN CERTAIN LOCALITIES. 



385 



Case 1. Taken at the age of one week; recovered in two days. Dr. 
Sims, Amer. Journ. of Med. Sci., April, 1846. 
" 8. Female ; taken at the age of three days; recovered in five weeks. 
The writer. 

Period of Commencement. — Finckh, who saw cases of tetanus of 
the new-born in the Stuttgart Hospital, states (Seeker's Annalen, 
vol. iii. No. 3, p. 304) that it began in one case on the second day 
after birth, in eight on the fifth, and in seven on the seventh. 

Professor Cederschjold, of Stockholm, treated forty-two cases 
in hospital practice in 1834, and in these cases it usually com- 
menced between the ages of four and six clays. Copland says (Medi- 
cal Dictionary) that it generally commences in the first seven or 
nine days after birth, and rarely later than the fourteenth. Rom- 
berg states that it commences between the fifth and ninth days. 
In two hundred cases observed by Peicke, in Stuttgart, in the 
course of forty-two years, it was never found to commence before 
the fifth, rarely after the ninth, and never after the eleventh day. 
Schneider says that the disease occurs oftenest between the second 
and seventh, and rarely after the ninth day. In six cases reported 
by Dr. C. Levy, of Copenhagen, it began in two on the third day, 
in two on the fifth, and in two on the sixth. Dr. Greenville 
Dowell (Amer. Journ. of Med. Sci., Jan. 1863), who has seen much 
of tetanus infantum among the negroes in Mississippi and Texas, 
says it is almost sure to come on between the fifth and twelfth 
days after birth. In the forty cases embraced in the above table, 
the disease beo-an as follows : — 

a 

Cases. 



Very rarely, as will be seen hereafter, tetanus begins at or soon 
after birth, that it may be properly called congenital. 

Frequency in Certain Localities. — Tetanus infantum oceurs 
probably in all countries, but it does not greatly increase the mor- 
tality except in certain localities. Some of the British and conti- 
nental physicians whose observations of disease have been ample, 
confess that they have seen so few cases that they have almost no 
personal knowledge of this affection. On the other hand, there 
are, or have been, places in every zone where it is or has been so 
25 



Age. 
One day or 
Two days 
Three " 


under . 


Cases. 
. 2 
. 1 
. 9 


Age. 
Seven days . 
Eight " . 
Ten " . 


Four " 


. 


. 2 


Eleven " . 


Five ■" 




. 6 


Twelve " . 


Six " 


. 


. 3 





386 TETANUS INFANTUM. 

prevalent as to sensibly check the increase of population. The 
attention of the profession, more than half a century since, was 
directed to the prevalence of tetanus in the Island of Heimacy, off 
the coast of Iceland. On this island scarcely an infant escaped, 
while on the mainland scarcely one was affected. Heimacy, the 
product of volcanic action, of small extent and almost destitute of 
vegetation, supports a scanty population. The inhabitants live 
chiefly on the flesh and eggs of the sea-fowl, and are filthy and 
degraded in their habits. About the year 1810, the Danish 
government deputed the landphysicus of Iceland to visit Heimacy, 
and ascertain the nature of the disease which was so destructive to 
the infants. Although this gentleman, from his brief stay, saw no 
case himself, he obtained interesting particulars in reference to the 
disease from the priests and parents. At this time scarcely an 
infant escaped. Again, according to Dr. Schleisner, whose report 
in reference to the same locality was published forty years later, 
this disease was still the most fatal of all infantile affections. 

Tetanus infantum is also represented as very fatal in the Island 
of St. Kilda, off the coast of Scotland. In the temperate regions 
of America and Europe cases are not frequent, except occasionally 
in the poor quarters of the cities, in foundling hospitals, and 
rarely in country towns where the conditions are favorable for 
its occurrence. The records of the Dublin, Stuttgart, and Stock- 
holm lying-in asylums furnish many cases. In the town of 
Fulda, Germany, in 1802, Dr. Schneider saw six cases in fourteen 
days, while a midwife in the same place stated that she had seen 
more than sixty in nine years. 

But the greatest mortality from tetanus infantum is in the warm 
climates, both of the Eastern and Western Hemispheres. In the 
West Indies, the southern portion of the United States, the equa- 
torial regions of South America, and in the islands of Minorca 
and Bourbon, it has, in many localities, been the most frequent 
and fatal of infantile maladies. 

It is an interesting fact that in the warm regions of the United 
States the victims are chiefly negro infants. L. S. Grier, M.D., of 
Mississippi, says, in the N. 0. Med. and Surg. Journ., May, 1854 : 
"The first form of disease which assails the negro among us is 
trismus. The mortality from this disease alone is very great. No 
statistical record, we suppose, has even been attempted, but from 
our individual experience we are almost willing to affirm that it 
decimates the African race upon our plantations within the first 
week of independent existence. We have known more than one 



causes. 387 

instance in which, of the births for one year, one-half became the 
victims of this disease, and that, too, in spite of the utmost watch- 
fulness and care on the part of both planter and physician. Other 
places are more fortunate, but all suffer more or less ; and the 
planter who escapes a year without having to record a case of tris- 
mus nascentium may congratulate himself on being more favored 
than his neighbors, and prepare himself for his own allotment, 
which is surely and speedily to arrive." Dr. "Woo ten (N. 0. Med. 
and Surg. Journ., May, 1846) says: " It is a disease of fatal fre- 
quency on the cotton plantations in this section of Alabama." 
He has, however, never seen a white child affected with it. 

In New Orleans, according to the death statistics in our posses- 
sion, which, however, relate to only one year, tetanus infantum 
is the most fatal of all diseases except phthisis. Mr. Maxwell 
says, in the Jamaica Physical Journal (copied in the London Lancet, 
April 11th, 1835): "From observations that I have made for a 
series of years, ... I found that the depopulating influence of 
trismus neonatorum was not less than twenty-five per cent. It 
scarcely has a parallel within the bills of mortality." This gentle- 
man's observations relate to the West Indies. Similar statements 
are made in reference to this disease as it occurs in Cayenne and 
Demerara in South America. 

While tetanus infantum prevails in regions wide apart, and 
presenting very diverse climatic conditions, there is a similarity 
as regards the personal and domiciliary habits of the people who 
suffer most from its occurrence. It occurs chiefly among those 
who are filthy and degraded in their habits, who live, either from 
choice or necessity, in neglect of sanitary requirements. This fact 
aids us in an understanding of the 

Causes. — That uncleanliness and impure air are a cause of 
tetanus is as fully demonstrated as most facts in the etiology of 
diseases. The attention of the profession was forcibly directed to 
this cause by Dr. Joseph Clarke in a paper read before the Royal 
Irish Academy in 1789. This physician was in charge of the 
Dublin Lying-in Asylum, and had rightly concluded that the 
mortality among the new-born infants was due to imperfect venti- 
lation. Through his advice, apertures, twenty-four inches hj six, 
were made in the ceiling of each ward ; three holes, an inch in 
diameter, were bored in each window-frame; the upper part of 
the doors leading into the gallery were also perforated with sixteen 
one-inch apertures, and the number of beds was reduced. The 
result of these simple sanitary regulations may be seen from Dr. 



388 TETANUS INFANTUM. 

Clarke's own statement. He says: "At the conclusion of the year 
1782, of 17,650 infants born alive in the Lying-in Hospital of this 
city, 2944 had died within the first fortnight, that is, nearly every 
sixth child." The disease in nineteen cases out of twenty was 
tetanus. After the wards were better ventilated, namely, from 
1782 till the time of the preparation of Dr. Clarke's paper, 8033 
children were born in the hospital, and only 419 in all had died, 
or about one in nineteen. So impressed was Dr. Evory Kennedy, 
who at a later period had charge of the same asylum, with the 
belief that Dr. Clarke had discovered the true cause, and had been 
able in a great measure to prevent it, that he writes in his enthu- 
siastic way: "If we except Dr. Jenner, I know of no physician 
who has so far benefited his species, making the actual calculation 
of human life saved the criterion of hi3 improvements." The 
cases occurring in my own practice were all met in tenement- 
houses or shanties, where habits of cleanliness are impossible, 
and I have not yet seen, in the practice of others, nor heard of a 
case which occurred in the better class of domicils. The statements 
of physicians in the southern States, who speak from extensive 
observation among the negroes, are strongly corroborative of the 
idea that the disease is in great measure due to uncleanliness and 
impure air. 

Dr. Greenville Dowell, of Texas, states that he has been able to 
trace the disease to the old bedclothes, saturated with excrementi- 
tious matters, which are found in the negro cabins. In a paper 
published in the Nashville Journ. of Med. and Surg., June, 1851, by 
Prof. John M. "Watson, the frequency of this disease among the 
negroes is accounted for as follows: — 

""When called to see their children, we find their clothes wet 

around their hips, and often up to their armpits, with urine 

The child is thus presented to us, when, on examination, we find 
the umbilical dressings not only wet with urine, but soiled, like- 
wise, with faeces, freely giving off an offensive urinous and faecal 
odor, combined at times with a gangrenous fetor arising from the 
decomposition, not desiccation, of the cord." 

Another cause is believed to be some irritation in the bowels, 
as from retained meconium. Observers in the southern States and 
elsewhere .occasionally mention this as a cause. In one case 
treated by myself, there was obstinate constipation immediately 
before the attack, and in another diarrhoea preceded, and was the 
only apparent .cause. 

In certain cases the assignable cause is exposure to wet or cold, or 



causes. 889 

to a variable temperature, which, it is known, occasionally, causes 
tetanus in the adult. Prof. Cede rschj old attributed the epidemic 
which he observed in Stockholm to a sudden change of temperature, 
from hot weather in May, to frosty in June. In a case related by 
Dr. P. C. Gaillard, in the Southern Jonrn. of Med. and Pharmacy, 
Sept. 1846, the disease commenced as follows: The nurse came in 
with wet apron and clothes, in the evening; a short time after she 
had taken the child into her lap, it sneezed violently two or three 
times. At 10 P. M. tetanus began. In certain localities on the 
continent, where there are no parish churches, the frequent occur- 
rence of tetanus has been attributed by the physicians to the 
practice of carrying the infants to a distance to be christened, thus 
exposing them to the wind and often rain. Even in this city I 
have observed the same cause. The influence of the weather in 
the production of tetanus of the new-born is also shown by facts 
observed in the Stuttgart Hospital. In an aggregate of twenty- 
live cases treated in that institution, all but three occurred in the 
cold months. In the island of Cayenne, at a hamlet surrounded 
by mountains and dense forests, tetanus attacked only one in 
every twelve or fifteen of the infants. After a great part of the 
forests had been cut down, so as to allow access to the cold sea 
winds, almost all the new-born infants fell victims to tetanus. 
(Insel, Cayenne.) 

Hein relates that a citizen of Berlin lost, successively, two 
children with tetanus soon after birth. When the second child fell 
ill, he observed that its cradle was exposed to a current of air. 
At the third accouchement the position of the cradle was changed, 
and the infant escaped. Exposure to wet and cold has been long 
recognized as a cause of the disease. According to Sauvages, 
"Hie morbus hieme et cum aura humida ssepius advenit quam 
sicca sestate." (Nosol. Method, vol. i. p. 531.) 

The causes of infantile tetanus, enumerated above, may be proxi- 
mate or remote, may produce the disease by their direct effect 
on the system or by producing a pathological state which in 
turn leads to the development of the disease. There are other 
direct causes, namely, organic affections. In the bodies of those 
who die of this disease lesions are observed which doubtless result 
from the spasms. Again, others are found, which, from their 
nature, could not be a result, and which, being observed in different 
cases, are to be regarded as direct causes. The most frequent of 
such lesions is inflammation of the umbilicus or umbilical vessels. 

Moschion, who lived in the first century of the Christian era, 



390 TETANUS INFANTUM. 

stated in writings still extant that stagnant blood in the umbilical 
vessels sometimes produced dangerous disease in the new-born 
infant, and it is supposed, though this is doubtful, that he referred 
to tetanus. In modern times the attention of the profession was 
more particularly directed to this cause by a paper published by 
Dr. Colles, in the first volume of the Dublin Hospital Reports, in 
1818. The observations published in this paper were made in 
the Dublin Lying-in Hospital during the period of five years. In 
each of these years he had witnessed from three to five post-mortem 
examinations in cases of infantile tetanus, and the lesions, he 
states, were in all much alike as follows : The floor of the umbilical 
fossa was lined by a membrane apparently formed by suppurative 
inflammation, and in the centre of this fossa was a large papilla. 
This papilla consisted of a soft yellow substance, apparently the 
product of inflammation, and in all the cases the umbilical vessels 
were in contact with this substance and were pervious. In a few 
instances superficial ulcerations were found near the mouth of the 
umbilical vein, and occasionally the skin surrounding the umbilicus 
was raised. The peritoneum covering the vein was highly vascular, 
often not to a greater distance than an inch above the umbilicus, 
but sometimes as far as the fissure of the liver. The peritoneum 
in the course of the umbilical arteries presented the inflammatory 
appearance in still greater degree sometimes as far as the sides of 
the bladder. The connective tissue lying along the arteries and 
urachus anteriorly was loaded with a yellow watery fluid. The 
inner surface of the umbilical vein was not inflamed, but its coats, 
in general, were thickened. On slitting open the arteries, a thick 
yellow fluid, resembling coagulable lymph, was found within their 
coats, and in all cases these vessels were thickened and hardened 
as far as the fundus of the bladder. 

Dr. Finckh, who observed twenty-five cases in the Stuttgart 
Hospital, believes that the most frequent cause was suppuration 
or ulceration of the umbilical cord. In ten of the twenty-five 
cases the navel was dry and cicatrized; in the remainder it was 
either wet or swollen, with a bluish-red inflamed edge at the 
margin of the navel; a dirty viscid pus covered the umbilical 
depression. 

Dr. Levy, physician of the Foundling Hospital in Copenhagen, 
attended twenty-two cases in that institution in 1838 and '39. 
Of these, twenty died, and fifteen were examined carefully after 
death. In fourteen there were decided marks of inflammation in 
the umbilical arteries, especially those portions lying along the 



CAUSES. 391 

urinary bladder ; in several cases the peritoneum over the arteries 
was much injected, and in three adherent either to the omentum 
or intestine by coagulable lymph ; the coats of the arteries were 
thickened, their cavities dilated and containing dark reddish-brown 
or greenish puriform matter, always fetid. Sometimes the arterial 
tunica interna was found ulcerated and absent in places, and there 
was spongy thickening of the subjacent connective tissue. In two 
cases the ulcerative process had extended from the tunica interna 
to the peritoneum, and there was a deposit of thick ichorous 
matter around the ulcer ; in one case both arteries were so softened 
that their coats were scarcely distinguishable, and in another these 
vessels had become gangrenous. The appearance of the umbilicus 
was unchanged in four cases ; in ten the fundus was red and filled 
with puriform fluid, which quickly reappeared when removed, 
and, in general, shortly before death the navel presented a greenish 
color. 

According to Romberg, Dr. Scholler made post-mortem examina- 
tions in eighteen cases of tetanus infantum, and in fifteen found 
inflammation of the umbilical arteries. These vessels were swollen 
near the bladder, in one case to the diameter of four lines, and were 
found to contain pus. The lining membrane was eroded or covered 
with an albuminous exudation. Both arteries were not always 
equally inflamed, and in three cases only one was affected. 

Schneeman found minute points of suppuration in the umbilical 
vein in eight cases (Holscher's Annalen, vol. v. p. 484, 1840), and 
pus throughout the course of this vessel in one. 

The observations mentioned above were made, for the most part, 
in hospitals on the Continent ; but similar observations have been 
made in private practice. M Boiran, of the Isle of Bourbon, says 
that he has found in every case inflammation around the umbilicus 
{Gazette Medicate, Paris, July 11, 1841). Dr. John Furlonge 
(Edin. Med. and Surg. Journ., Jan. 1830), who resided at St. 
John's, Antigua, attributes the disease to improper dressing of the 
umbilicus. The same opinion is expressed by Mr. Maxwell, who 
also saw the disease in the West Indies (Jamaica Phys. Journ., 
copied into the London Lancet, April 11, 1855). Dr. Ransom 
states, in a communication to Prof. John M. Watson (Nashville 
Journ. of Med. and Surg., June, 1851) that he has never seen a case 
of tetanus of the new-born in which the umbilicus was healthy. 
In a case related by Robert S. Baily, in the Charleston Med. Journ. 
and Rev., Nov. 1848, there was a hard scab on one side of the 
umbilicus, and this part was much distended. A discharge fol- 



292 TETANUS INFANTUM. 

lowed the removal of the scab, and the child recovered. In a 
favorable case, related by W. B. Lindsay, in the JV. 0. Med. and 
Surg. Journ., Sept. 1846, the umbilicus was tumid, and not disposed 
to heal. Dr. H. 0. Wooten (same journal, May, 1846) attributes 
the disease to the condition of the umbilicus and umbilical vessels, 
and states that he has found the umbilicus gangrenous. In a case 
related in the M 0. Med. and Surg. Journ., May 1, 1853, the um- 
bilical vessels were blocked up by purulent matter. Robert A. 
Chime, M.D., Brazoria, Texas (N. 0. Med. and Surg. Journ., Sept. 
1854), believes one cause of the disease to be improper tying and 
management of the umbilical cord, by which a diseased state is 
produced, which extends to the umbilicus, and thence to the vis- 
cera. At a meeting of the Obstetrical Society of Edinburgh, held 
April 24, 1850, Dr. Imlach related a case in which there was a dark 
and gangrenous appearance of the integument around the um- 
bilicus, and the peritoneum underneath was also dark, but not 
inflamed ; umbilical vein healthy ; a little fibrin in the left um- 
bilical artery ; right umbilical artery much diseased ; its two inner 
coats apparently destroyed, and in their place a yellow pultaceous 
slough, in which pus-globules were discovered with the micro- 
scope. 

It is evident that the pathological state of the umbilicus and 
umbilical vessels described above, and which has been noticed by 
so many observers in different countries, cannot result from the 
tetanus. It is possible that the puriform substance noticed in the 
umbilical vessels was disintegrated fibrin, which had coagulated 
at the time of ligation of the cord, and the cells seen by Dr. 
Imlach and others may sometimes have been white corpuscles still 
remaining from the stagnated blood. (Virchow's Celhd. Pathol.) 
Still, the evidences of inflammation, in at least a part of the cases 
related above, were of a positive character. 

The belief that umbilical lesions sometimes cause tetanus in- 
fantum comports with the well-known traumatic causation of teta- 
nus in the adult. This belief is strengthened by the fact, which 
will appear further on in our remarks, that this disease of the new- 
born, from being frequent in certain localities, has become infre- 
quent through greater care in dressing and managing the umbilical 

cord. 

But there are cases of tetanus infantum in which there is no 
disease in or about the umbilicus. Dr. Finckh, of Stuttgart, 
examined the umbilical vessels in eleven cases without discovering 
any pathological change. Dr. Samuel B. Labatt, master of the 



causes. 393 

Dublin Lying-in Hospital, published in the JEJdin. Med. and Surg. 
Journ., April, 1819, a paper entitled "An Inquiry into an Alleged 
Connection between Trismus Xascentium and certain Diseased 
Appearances in the Umbilicus.'' This paper was designed as a 
reply to the essay of Dr. Colles. Dr. Labatt relates several cases in 
which there was no disease of the umbilicus and umbilical vessels, 
and others in which the disease was so slight that it probably pro- 
duced no injurious effect on the health of the child. Dr. James 
Thompson, who spent considerable time in the tropical regions, 
says {Edin. Med. and Surg. Journ. : Jan. 1822): "I have myself 
examined nearly forty cases of infants that have sunk under this 
complaint. In many I have looked at no other part but the navel, 
and have found it in all states ; sometimes perfectly healed, espe- 
cially if the infants had lived several days ; at other times a simple 
clean wound. When death occurred on the fifth or sixth day, the 
wound was frequently in a raw state. I never yet saw it in a 
sphacelated condition." This writer concludes from his observa- 
tions that there are cases in which the cause is located elsewhere 
than in the umbilicus or umbilical vessels. In the Dub. Journ. of 
Med. and Chem Sci., Jan. 1836, Dr. John Breen remarks: "From 
dissections ... we have never been able to discover any peculiar 
morbid appearance which would justify us in offering any explana- 
tion of the pathology of the disease." In my own cases there was 
no evidence of disease of the umbilicus or umbilical vessels so far 
as could be ascertained by external examination, and in one (No. 32) 
a careful post-mortem examination disclosed no lesion of these 
parts. 

The inference from the above observations is that, although 
umbilical disease may be an occasional, probably not infrequent, 
cause of tetanus infantum, cases occur in which such disease is not 
present, and we must look for the cause elsewhere. From the 
nature of tetanus infantum, the cerebro-spinal axis has been from 
time to time examined in those who have died of this disease, and 
occasionally sufficient cause has been found in this part of the 
system. 

I have alluded in another connection to a case from Billard, in 
which tetanic rigidity occurred in an infant three days old, as the 
result of spinal meningitis. That tonic spasms not infrequently 
occur in older children in consequence of meningeal inflammation 
is well known, and in some of the reported epidemics of infan- 
tile tetanus meningitis was really present, and was doubtless the 
cause of the tonic spasms. Such an epidemic was observed by 



394 TETANUS INFANTUM. . 

Professor Cederschjold in Stockholm, in 1834. Within a few 
months he treated forty-two cases, and, in addition to the lesions 
which are known to result from tetanus, there was found in the 
hodies examined a plastic exudation at the base of the brain. 
Finckh, of Stuttgart, made twenty post-mortem examinations of 
those who had died of this disease, and in nine found spinal menin- 
geal inflammation. 

Meningitis in the new-born infant is, however, rare, and we 
must regard it as an exceptional cause of tetanus. 

In 1846 there appeared from the pen of Dr. Sims, then practis- 
ing at Montgomery, Alabama, a paper designed to show that 
tetanus of the new-born is produced by pressure exerted on the ner- 
vous centre, through depression of the occipital bone. In 1848 the 
same writer published a second paper, also in the Amer. Journ. of 
Med. ScL, fully enunciating his theory as follows : "That trismus 
neonatorum is a disease of centric origin depending on a mechani- 
cal pressure exerted on the medulla oblongata and its nerves ; that 
this pressure is the result, most generally, of an inward displace- 
ment of the occipital bone, often very perceptible, but sometimes 
so slight as to be detected with difficulty ; that this displaced con- 
dition of the occiput is one of the fixed physiological laws of the 
parturient state ; that when it persists for any length of time after 
birth it becomes a pathological condition, capable of producing all 
the symptoms characterizing trismus neonatorum, which are in- 
stantly relieved simply by rectifying this abnormal displacement, 
and thereby removing pressure from the base of the brain." In 
both papers cases are narrated in support of this theory, but there 
are serious objections to this mode of explaining the occurrence of 
the disease. In the first place, if this explanation were correct, 
tetanus ought ordinarily to occur sooner, for the occiput is as much 
depressed previously, and in the majority of cases more depressed 
than at the period when it does actually commence. Pressure on 
the medulla would certainly be followed by immediate and marked 
symptoms, instead of an immunity for four or Hve days. 

Again, well-known facts in reference to the causation of teta- 
nus infantum conflict with Dr. Sims's theory, as, for example, epi- 
demics of the disease, its prevalence in one locality and absence in 
another, although no particular attention is given to the position 
of the infant, the diminution of the number of cases by greater 
attention to cleanliness, of which there is abundant proof. More- 
over, there are many reported cases of this disease at the commence- 



causes. 395 

ment of which there was no perceptible displacement of the occipital 
bone. 

The inequality of the cranial bones often observed in tetanus 
infantum should, in my opinion, be explained as follows : "When 
the new-born infant becomes emaciated, the volume of the brain is 
diminished, like that of the trunk or limbs, and the sinking of the 
occipital bone simply corresponds with the amount of waste in the 
cerebral substance. Whatever the disease in the young infant, if 
there is much emaciation, the parietal bones will usually be found 
more prominent than the occipital. Now, in fatal tetanus 
infantum, emaciation is very rapid; those fleshy and plump, if 
the disease do not speedily end, become pinched and wrinkled. 
Viewed in this light, the occipital depression should be regarded 
as a result, and not cause, of the tetanus. 

Although we do not accept the theory which attributes tetanus 
infantum to occipital depression, there are a few cases on record 
in which it was apparently due to injury of the head received at 
birth. Dr. Sims has related one such case, that of a negro infant. 
The mistress, an observing lady, gave to Dr. Sims the following 

account of it: Its head was "mightily mashed The bones 

seemed to be loose. I got it to take a little boiled milk on the 
first day ; but it swallowed very little and very badly, for its jaws 
seemed to be locked. On the next day it took spasms and got 
stiff all over ; its hands were shut up tight, and its arms were bent 
up so (she placed her forearms at right angles). Every time I 
touched it the spasm would get worse all over, screwing up its face 
till it was the ugliest thing in the world ; and when the spasms 
wore off it looked as well as any other new-born baby. But then 
the stiffness never left it, and the spasms kept coming and going 
till it died." It lived two days. 

It is evident, from the description given by the mistress, that this 
was a case of tetanus commencing at or so soon after birth that 
it seemed almost congenital. The apparent cause was injury of 
the head, occurring in consequence of protracted birth, the infant 
being resuscitated with difficulty after several minutes. 

Dr. W. C. Sutton published a similar case in the Nashville Journ. 
of Med. and Surg., April, 1853. The infant at birth was apparently 
dead, but was resuscitated so as to live eighteen hours in a state of 
tetanic rigidity. In cases in which tetanus begins at birth, doubt- 
less, the cerebro-spinal axis is in some way affected ; but in the ab- 
sence of post-mortem examinations, the exact nature of the lesion 
is uncertain. 



396 TETANUS INFANTUM. 

It is evident, therefore, that in this disease, as in eclampsia, the 
cause in different cases may be entirely distinct. Dr. James John- 
son, many years ago, expressed his belief in the multiplicity of 
causes, and he had been a careful and intelligent observer in the 
West Indies. 

The causes may be arranged in two groups, one external, the 
other internal. In the first group should be placed imperfect 
ventilation, personal and domiciliary uncleanliness, and atmospheric 
vicissitudes ; in the second group, so far as ascertained, inflamma- 
tion of the umbilicus and umbilical vessels, meningitis, and, 
rarely, injury of the cerebro-spinal axis during birth. 

The lesions resulting from tetanus infantum pertain chiefly to 
the circulatory system. In the cases examined by Prof. Ceder- 
schjold, of Stockholm, already alluded to, the meningeal and 
cerebral vessels, and those of the spinal cord, the cavities of the 
heart, and the large vessels connected with the heart, were dis- 
tended with blood. 

Finckh made post-mortem inspection of twenty cases in the 
Stuttgart Hospital, the bodies, at death, having been placed on 
their faces, in order to prevent any deceptive appearance from 
the gravitation of blood. In four there was no appreciable altera- 
tion in the spinal cord or its membranes. In the remaining six- 
teen there was effusion of blood, in considerable quantity, the 
wnole length of the spinal cord, between the bony walls and the 
dura mater. It should be stated, however, that there was spinal 
meningeal inflammation in nine of the sixteen, though the extra- 
vasation did not, probably, result from the inflammation, but from 
the tetanus. The blood in Finckh 's cases was very dark, some- 
times fluid, at other times coagulated. In one case there was no 
change in the appearance of the brain or its membranes. In the 
remaining nineteen, more or less extravasated blood was found on 
the surface of the brain, or in its interior. The substance of the 
brain was healthy, as also its membranes, except the congestion. 
The only abnormal appearance observed in the thoracic and 
abdominal viscera was strong contraction of some portion of the 
intestinal tube in five cases. Dr. West says: "The most frequent 
post-mortem appearance in these cases" — referring to tetanus 
infantum — "and that which I found in the bodies of all the four 
children whom I observed, consists of effusion of blood, either 
fluid or coagulated, into the cellular tissue surrounding the theca 
of the cord. Conjoined with this there is generally a congested 
state of the vessels of the spinal arachnoid, and sometimes an effu- 



causes. 397 

si on of blood or serum into its cavity. The signs of congestion 
about the head are less constant, though much oftener present than 
absent, and sometimes existing in an extreme degree; while in 
one instance I found not merely a highly congested state of the 
cerebral vessels, but also an effusion of blood, in considerable 
quantity, between the skull and dura mater, and also a slighter 
effusion into the arachnoid cavity." Dr. Weber, of Kiel, also 
placed infants who had died of tetanus on their faces, and, with- 
out exception, found injection of the capillaries of the cord and 
spinal meninges, and extravasation of blood. M. Matuszynski, 
according to Bouchut, "has observed effusions of blood, of variable 
quantity, in the cerebral pia mater, in the ventricles, and in the 
choroid plexuses, with considerable injection of the membranes of 
the brain. He has also seen serous infiltration beneath the arach- 
noid, and serous effusion into the ventricles, accompanied by a 
diminution of the consistence of the cerebral substance." In two 
cases examined by myself, there was intense injection of the cere- 
bral meninges, and of the meninges of the upper part of the spine, 
but no extravasation was noticed. The spinal canal was not 
opened. In a third case, in which the spinal canal was opened, 
there was extravasation in addition to the congestion; this was 
especially observed along the spinal theca. 

Dr. H. 0. "Wooten (iY. 0. Med. and Surg. Journ., May, 1846) states 
that he has made several post-mortem examinations, and has found 
the pathological appearances as uniform as in any other disease, as 
follows : " Engorgement of the substance of the brain, and of the 
meninges lining the base of the brain, the medulla oblongata, and 
spinal marrow; liver congested." 

In a case related by Dr. Imlach before the Edin. Obst. Soc, 
April 24, 1850, the upper part of the lungs was healthy, the poste- 
rior portion congested, and containing many dark points ; heart 
and liver healthy; small intestines of a light-brown color; stomach 
and large intestines pale ; there had been umbilical hemorrhage. 

Romberg states that he found in a child, whose death occurred 
from this disease, such intense congestion of the veins and sinuses 
of the brain, that a slight touch, and the removal of the cranial 
bones, produced extravasation of the partly coagulated and partly 
fluid blood. Dr. Scholler, on the other hand, found actual extrava- 
sation of blood in the spinal canal in only one case in eighteen. 

It is seen from the above observation, that tetanus of the infant 
is ordinarily accompanied by great passive congestion, which is 



398 TETANUS INFANTUM. 

especially marked in the cerebro-spinal axis, and that frequently 
extravasations occur from the distended capillaries. The embar- 
rassment of respiration and the retarded circulation of blood con- 
sequent on the tetanic rigidity afford sufficient explanation of this 
state of the vessels. 

Symptoms. — In many cases premonitory symptoms are absent, 
or are so slight as to escape notice. Sometimes there is a degree 
of fretfulness previously, but no more than is often observed in 
those who continue in good health. The first symptom which 
alarms the parents, and shows the grave nature of the commenc- 
ing disease, is inability to nurse, or evident pain and hesitation 
in nursing. Commencing with rigidity of the masseters, the dis- 
ease gradually extends to the other voluntary muscles, and in the 
course of a few hours the muscles of the limbs, as well as of the 
trunk, are involved. Persistent muscular contraction, which is 
the pathognomonic feature of infantile tetanus, is developed not 
fully in the beginning, but by degrees in each affected muscle, 
so that it is not till after the lapse of several hours, perhaps even 
a day, that the greatest amount of rigidity is attained. Therefore, 
in the commencement of the disease, the limbs can be bent, and 
the jaws pressed open, more readily than at a subsequent stage, 
though with manifest pain to the infant. 

During the period of maximum rigidity, the jaws are fixed 
almost immovably, often with a little interspace between them, 
against which the tongue presses, and in which frothy saliva col- 
lects. The head is thrown backward and held in a fixed position 
by the stiffness of the cervical muscles. The forearms are flexed ; 
the thumbs are thrown across the palms of the hands, and are 
firmly clenched by the fingers ; the thighs are drawn towards the 
trunk; the great toes are adducted, and the other toes flexed. Oc- 
casionally opisthotonos results from the extreme contraction of the 
dorsal and posterior cervical muscles. The infant can sometimes 
be raised without any yielding of the muscles, by one hand under 
the occiput and the other under the heels. 

The rigidity is liable to variation in its intensity, even after the 
full development of the disease. If the infant is quiet, especially 
if asleep, the muscles are partially relaxed to such an extent, some- 
times in the first stages of the complaint, that the features have a 
placid and natural expression, though only for a short time. There 
are frequent exacerbations in the muscular contraction, sometimes 
occurring without any apparent cause, and sometimes produced by 
anything which excites or disturbs the child. Attempts to open 



symptoms. 399 

the lips or jaws, or eyelids, or to bend the limbs, blowing on the 
face, or even the crawling of a fly upon it, occasions the paroxysm. 

During the paroxysm the eyelids are forcibly compressed, as well 
as the lips, which are either drawn in or are pouting; the forehead 
and cheeks are thrown into wrinkles, and the physiognomy is 
indicative of great suffering. The unnatural positions of the 
trunk and limbs, which result from the muscular contraction, are 
increased for the moment ; the head is more forcibly thrown back, 
and the limbs more strongly flexed. The muscular movements 
which occur during the paroxysms are sometimes described as 
clonic spasms. There is indeed occasionally some quivering of the 
limbs, and yet, as I have on different occasions noticed, so far from 
the muscular action being a clonic spasm, it possesses a tonic cha- 
racter, which is at times intensified. In fatal cases the paroxysms 
occur more and more frequently until the period of collapse. 

The crying of the child affected by tetanus is never loud, how- 
ever great the suffering. It is variously described by writers as 
"whimpering" or "whining." It is of this suppressed character 
in consequence of the rigid state of the respiratory muscles and 
their imperfect movement. 

During the exacerbation respiration is suspended, or so imper- 
fect, and the circulation so retarded, that the surface becomes of a 
deep red, almost livid, color. Sometimes epistaxis occurs, affording 
partial relief to the congestion, and sometimes, though less fre- 
quently, the blood forces itself from the congested liver along the 
umbilical vein, and escapes from the umbilicus. I have already 
alluded to the occurrence of meningeal apoplexy. 

The frequency of the pulse and respiration varies in different 
cases, and at different stages of the same case. They are often 
somewhat accelerated, but at other times are natural, or are even 
slower than in health. 

"While the appetite of the infant, to appearance, is not dimin- 
ished, the pain which it experiences in nursing is such that 
alimentation is necessarily deficient. It can be fed with a spoon 
for a time after it ceases to take food in the natural way, but arti- 
ficial feeding soon fails. The milk placed in its mouth is in great 
part pressed back through the violence of the spasm which is 
induced by the attempt to feed it. 

In consequence of imperfect nutrition, the infant rapidly wastes 
away. There is no other disease except the diarrhceal affections 
in which emaciation is so rapid. In a case related by Dr. "W*. B. 
Lindsay in the N. 0. Med. Journ., Sept. 1846, the record states 



400 TETANUS INFANTUM. 

that "the infant was fat three days before, but was now emaci- 
ated." Romberg, who saw tetanus infantum in European hospi- 
tals, and Dr. Robert H. Chinn, of Texas (A. 0. Med. and Surg. 
Journ., Sept. 1854), both speak of the rapid emaciation. The trunk 
and extremities lose their fulness, and the features become pinched. 
Several observers have noticed the appearance of miliaria in this 
reduced state of system, especially around the shoulders, and some- 
times a decidedly icteric hue appears on the skin. 

The condition of the bowels is not uniform. They may be 
relaxed, particularly if the disease is due to some irritation in 
them ; in other cases the stools are natural or constipated. 

It is often difficult to ascertain the state of the eyes, since 
attempts to open the eyelids bring on spasms and cause firm 
compression of the lids against each other. According to Sir 
Henry Holland, one of the first symptoms which occurred in cases 
on the island of Heimacy, was strabismus, with rolling of the 
eyes. But this statement must be received with caution, since 
these cases were not seen by any physician, and the information 
was obtained from the parents and priests. If true, the proximate 
cause of the disease in Heimacy would seem to be located in the 
cerebro-spinal axis. Contraction of the pupils commonly occurs in 
the stage of collapse. 

Mode oe Death. — Death in infantile tetanus may occur from 
apnoea in the paroxysms, from extreme congestion of the cerebral 
vessels, or apoplexy ; and, lastly, it may occur from exhaustion. 
The last mode is, probably, the most frequent. 

Prognosis. — All writers till recently agree that tetanus of the 
infant rarely terminates favorably. Cullen attributes the ignorance 
of physicians in regard to this disease to the fact that it is so little 
amenable to treatment, that they are not usually summoned to 
attend those affected w^ith it. In the island of Heimacy, of one 
hundred and eighty -five cases, occurring during a series of years 
about the commencement of the present century, not one survived ; 
and in the same locality, at a more recent period, according to the 
report of Dr. Schleisner already alluded to, sixty-four per cent, 
died. Similar statements in regard to the mortality of tetanus 
infantum are given by physicians in the southern States. Dr. 
H. 0. "Wooten, of Alabama, says (A. 0. Med. Journ., May, 1846) that 
he has " never seen a decided case of tetanus nascentium that did 
not prove fatal ; . . . and that it is very generally deemed useless 
to call in medical aid after the initiatory symptoms are well 
declared." Mr. Maxwell, speaking in reference to the West Indies, 



DUKATION IN FATAL CASES. 401 

says {Jamaica Phys. Jburn., copied into the London Lancet, April 
11th, 1835): "From observations which I have made for a series 
of years, ... I found that the depopulating influence of trismus 
nascentium was not less than twenty-five per cent. It scarcely has 
a parallel within the bills of mortality." Dr. D. B. JSTailer (N. 0. 
Med. Journ., Nov. 1846) says: "About two-thirds of the deaths 
among the negro children are from this disease, and so uniformly 
fatal is it, that a physician is never sent for." 

Yet death does not always result. Eight of the forty cases in my 
collection recovered ; but a correct opinion cannot be formed from 
this of the actual ratio of favorable to unfavorable cases, since 
favorable cases are much more likely to be published. In the 
history of these eight cases, two interesting facts are noticed, 
which, when present, may serve as a ground for hope of a successful 
termination. These were, the age at which the disease began, and 
fluctuation in the symptoms. "With two exceptions, the infants 
who recovered were about a week old when the initiatory symp- 
toms appeared, and there were fluctuations in the gravity of the 
symptoms ; whereas, fatal cases ordinarily grow progressively worse. 
Yet, in favorable cases, the symptoms are never so severe as they 
become in a few hours in those who succumb. 

Duration in Fatal Cases. — Of eighteen cases observed by Finckh 
in the Stuttgart Hospital, fifteen died in two days, two in five 
days, and one in seven days. During the epidemic in the Stock- 
holm hospitals, in 1834, where forty-two cases were treated, the 
disease seldom lasted more than two days. Romberg says: "It 
generally lasts from two to four days, but its duration is at times 
limited at from eight to twenty-four hours, and occasionally, 
though rarely, it extends from five to nine days." 

In thirty -one fatal cases in my collection, in which the duration 
is mentioned — 

One lived 3 hours. 

Eleven others lived 1 day or less. 

Twelve lived 2 days. 

Four " 3 " 

Three " 4 " 

Both Underwood, who published a little treatise on diseases of 
children, in 1789, and. Dr. Elsasser at a more recent date, record 
fatal cases which were unusually protracted. The one described 
by Underwood was treated in the British Lying-in Hospital, and, 
although all the others treated in this institution died by the third 
day, this lived six weeks; but it is suggested by the author, that 
26 



402 TETANUS INFANTUM. 

death was due in part to some other affection. The child treated 
by Elsasser lived thirty-one days. 

Duration in Favorable Cases. — In the eight favorable cases in 
my collection, the duration of the disease, reckoned from the time 
when the infant ceased nursing till it began again, was as follows : 
In one case, two days ; in one, a few days ; in one, fourteen days ; 
in two, fifteen days ; in one, twenty-eight days ; in one, twenty-one 
days; and in the remaining case, about five weeks. 

Diagnosis. — To one who has seen this disease in the new-born, 
or is familiar with its symptoms, diagnosis is easy. The symptoms 
which possess diagnostic value are more manifest and reliable than 
in most other infantile affections. Permanent rigidity of the 
voluntary muscles, with temporary exacerbations, such as have 
been described above, which are induced by any cause which 
disturbs the infant — as attempts to open the mouth or eyelids — is 
pathognomonic. 

Preventive Treatment. — While tetanus infantum, if fully 
developed, is ordinarily fatal, in spite of any remedial measures 
heretofore used, there is no doubt of the efficacy and value of 
preventive measures, when properly employed. This was shown 
by the great reduction in mortality in the Dublin Lying-in Hos- 
pital through the thorough ventilation introduced by Dr. Clarke. 
Dr. Meriwether, of Montgomery, Ala., says (Amer. Journ. of Med. 
Sci., April, 1854): "When the disease appears endemically on a 
plantation, it may be arrested by having the negro houses white- 
washed with lime, inside and out ; by raising the fioors above the 
ground ; by removing all filth from under and about the houses ; 
by particular attention to cleanliness in the bedding and clothes 
of the mother ; and in the dressing of the child, so as to prevent 
any of the matter from the umbilicus lying long in contact with 
the skin." Many physicians, especially in the Southern States, 
speak confidently of care in dressing the cord, and attention to the 
umbilicus, as a means of prevention. In the N. 0. Med. and Surg. 
Journ., July, 1853, Dr. Grafton says that he has "never known the 
disease to occur in any child whose navel had the turpentine 
dressing." He uses turpentine as follows: "At the first time, a 
few drops of the undiluted turpentine are applied immediately to 
the umbilicus around the cord, and it is anointed at every suc- 
ceeding dressing, the turpentine being diluted one-half or two- 
thirds with olive oil, lard, or fresh butter." This use of turpentine 
has also been recommended by other practitioners in the warm 
regions. 



TREATMENT. 403 

Dr. John Furlonge, of St. John's, Antigua, believes (Edin. Med. 
and Surg. Journ., Jan. 1830) that no case would occur with the 
following treatment : " The cord, when divided, should he wrapped 
in clean linen. Every night, for two weeks, one or two drops of 
tinct. opii and spts. vini, equal parts, should be given, and castor 
oil, with a little magnesia, every morning. The child must be 
washed in tepid water every morning, and the funis dressed." If 
this treatment is attended by the success which is claimed for it 
by Dr. Furlonge, so great care in dressing the cord is certainly 
well repaid in localities, as at Antigua, where a large proportion 
of the infants die of tetanus. 

Some experienced observers go so far as to assert that it is 
possible to ward off tetanus infantum after the occurrence of pre- 
monitory symptoms. Dr. Dowell says (Amer. Journ. of the Med. 
Sci., January, 1863): "Some with slight twitchings of the muscles, 
have recovered without any trouble by being put into a mustard- 
bath, washed clean, and put in a clean and well-ventilated cabin." 

Treatment. — In considering the effect of medicinal agents which 
have been employed in the treatment of infantile tetanus, the 
great difficulty which the child experiences in swallowing should 
be borne in mind. Without care, a considerable part of the dose 
is lost by the spasm of the muscles of deglutition, which ordinarily 
occurs when the spoon is placed in the mouth, so that, unless 
special attention is given to this matter, it is uncertain whether 
the prescribed dose is fully administered. 

The treatment employed by different physicians has been very 
diverse. Antiphlogistic remedies were prescribed by Finckh, but 
every case so treated was fatal. He states that whenever blood 
was abstracted, even in small quantities, the symptoms were 
aggravated. The same result has followed depletory measures in 
the practice of other physicians. 

The internal remedies which have been most frequently pre- 
scribed are opiates and antispasmodics. Furlonge, in a favorable 
case, gave laudanum, in doses of one drop every three hours, 
alternately with two grains of Dover's powder. Woodworth also 
gave one-drop doses of laudanum ; Eberle, one-sixth of a drop 
hourly. The opiate has generally been given in combination with 
an antispasmodic. The Dover's powder, given every three hours 
by Furlonge, was combined with fi.ve grains of sulphate of zinc. 
The hourly doses of laudanum, by Eberle, were combined with six 
drops of tincture of assafoetida. 



404 TETANUS INFANTUM. 

When anaesthetics began to be employed in the treatment of 
diseases it was believed that they would be especially useful in 
cases of tetanus. Accordingly chloroform has been used in tetanus 
in the infant, with the effect of controlling the spasms during the 
time of its use, but without curing the disease. In Case 7 in our 
first table it was employed several times, but apparently without 
delaying the fatal result. The editor of the New Orleans Medical 
and Surgical Journal states, in the May issue of that periodical for 
1853, that he has used chloroform in tetanus infantum, with the 
effect, he believes, of prolonging life. Anaesthetics certainly relieve 
the suffering of the infant, and on this account, even if they do 
not prolong life, their judicious employment seems proper. 

The remedy which, in my opinion, is far preferable to all others, 
is hydrate of chloral. Since the introduction of this agent into 
therapeutics, it has been employed by several physicians in the 
treatment of this disease with so good a result that it will prob- 
ably supersede all other medicines for this purpose. Dr. Wider- 
hofer, of Vienna, states that he has saved six out of ten or twelve 
by the use of chloral {London Lancet, March 18, 1871). He pre- 
scribes it in doses of one to two grains by the mouth, or, if there 
is great difficulty in swallowing, two to four grains by the rectum. 
Dr. F. Auchenthales relates a case (Jahrb.f. Kinderheil., ~N. S. IY.) 
in which he gave even six-grain doses, and in nine days the disease 
had entirely disappeared. I have employed hydrate of chloral in 
only one case of tetanus infantum, giving it in half-grain doses, 
every two hours, except when there was profound sleep. The 
disease was fully developed, and the symptoms severe when I 
was called. I did not believe that the infant with the old 
remedies would live more than two days, but by the chloral life 
was prolonged nearly one week. Moreover, by the use of chloral 
the suffering of the infant is greatly diminished. 

The administration of alcoholic stimulants is required at short 
intervals on account of the rapid emaciation and great prostration. 

Local treatment directed to the umbilicus in those cases in which 
there is evidence of inflammation of the umbilicus or umbilical 
vessels should not be neglected. Vesication of the umbilicus, and 
the application of poultices to it, have been followed by unques- 
tionable benefit, if we may believe the statement of some physicians 
who have made use of these ' measures. Dr. Merriwether, of 
Alabama, says, if there is no improvement from the medicine 
which he orders, he applies a blister, larger than a dollar, to the 



INTEENAL CONVULSIONS. 405 

umbilicus, and with this treatment the child generally improves ; 
a remarkable statement, since so few improve at all. 

A warm foot-bath repeated at intervals of a few hours, and 
stimulating embrocations along the spine, are proper adjuvants to 
the treatment. 



CHAPTER XIII. 
INTERNAL CONVULSIONS. 

Young children are liable to temporary suspension of respiration, 
induced by violent emotions, especially by anger. In the midst of 
their excitement, while they are crying or screaming, their breath 
is suddenly held, as if from tonic spasm of the respiratory muscles. 
In a few seconds respiration returns, and is natural. There is no 
stridulous inspiration or other unusual sound, and there is no 
apparent ill effect, unless occasionally a degree of languor. Ex- 
ternal convulsions, which seem to be threatening, seldom occur, 
and when they do, are ordinarily mild. Some writers consider 
dentition the predisposing cause of this arrest of respiration, by 
inducing a sensitive state of the nervous system. Such an effect 
of dentition is possible, but certainly many infants are affected in 
this manner before the age of dentition. 

A much more serious state, and one which is recognized as a 
true disease, is that variously designated by writers as internal 
convulsions, spasm of the glottis, child-crowing, laryngismus 
stridulus, etc. Manifest difficulties attend the investigation of the 
pathological state in this disease. There can be little doubt that 
it is not precisely the same in all cases. That there is, during the 
paroxysms, tonic or clonic spasm of more or fewer of the respiratory 
muscles is inferred not only from the symptoms pertaining to the 
respiratory apparatus, but from the fact that in severe cases there 
are often spasms of the external muscles, as those of the limbs and 
face. Usually, also, the movements of the eyeballs indicate 
spasmodic contractions of the motor muscles of the eyes. The 
occurrence of these contractions in parts that are visible justifies 
the belief that they occur in other parts which are concealed from 
view, especially as the characteristic symptoms cannot be readily 
explained except on this supposition. Trousseau says: "Internal 
convulsions consist, then, principally in a spasm of the diaphragm 



406 INTEKNAL CONVULSIONS. 

and of the respiratory muscles of the abdomen and chest ; but it 
occurs, also, that the muscles pertaining to the larynx are affected 
with spasm at the same time with these." Rilliet and Barthez 
conclude from the symptoms that the " heart is not always a 
stranger to this internal convulsion, which, perhaps, prolongs itself 
even to the intestines." The muscles of the pharynx appear to be 
involved, in some cases, as well as those of respiration, rendering 
deglutition difficult. In one form of internal convulsions, namely, 
that which is principally referred to by writers, there is not 
complete arrest of respiration, but the inspirations, during the 
paroxysm, are difficult and are attended by a stridulous noise. 
Again, the respiration may cease entirely, but when it commences 
it is stridulous, and difficult for a few inspirations. In still 
another form of the disease respiration ceases, but there is no 
symptom or sign indicative of glottic spasm or of an obstacle to 
the ingress of air ; the inspirations which succeed the paroxysm 
are easy and noiseless. It has been suggested that, in these cases, 
there is paralysis rather than spasmodic contraction of the respi- 
ratory muscles, but the symptoms may be explained in accordance 
with the commonly accepted opinion, namely, that there is spasm 
of the diaphragm and, perhaps, some of the muscles of the chest 
and abdomen, while the laryngeal muscles are not affected. M. 
Herard, indeed, who has written one of the best monographs on 
internal convulsions, describes three forms of the disease, according 
to the supposed location of the spasm, namely, laryngeal, dia- 
phragmatic, and another, which consists of a blending of the two. 

Internal convulsions are not frequent in this country ; they are 
rare in France, more frequent in Germany, and quite common in 
England. They occur, with few exceptions, before the age of two 
years. Dr. West observed thirty-one cases under the age of two 
years, and only six above that age. 

Causes. — The causes of internal convulsions are not fully ascer- 
tained. Most observers have remarked the relative frequency of 
the disease during the period of dentition, and it is probable that 
dental evolution does operate as a cause, by rendering the nervous 
system more impressible. 

Spasm of the glottis has been attributed to enlargement of the 
thymus gland, and also to enlargement of the cervical and bron- 
chial glands. It is presumed that this effect is due to the pressure 
of these glands on the par vagum, or the recurrent laryngeal nerve. 
It is certain, however, that there is no such enlargement of the 
thymus gland which could possibly produce glottic spasm, or any 



CAUSES. 407 

other form of internal convulsions at the age at which these con- 
vulsions commonly occur. This gland is largest in the new-born, 
and having no function after birth, it gradually becomes atrophied. 
If enlarged thymus could produce glottic spasm, it would certainly 
occur most frequently in the new-born. Abnormal development 
of the thymus gland was the only assignable cause of atelectasis in 
two infants who died soon after birth, but I have never seen a case 
in which a convulsive attack was referable to this cause. M. He- 
rard examined the thymus gland in six children who died of inter- 
nal convulsions, and in sixty who died of other affections, and was 
not able to discover in its condition any causative relation to this 
disease. Indeed, cases have been reported in which the thymus 
had undergone more than its usual atrophy at the time when the 
convulsions occurred (Hasse). Enlargements of the lymphatic 
glands in the vicinity of the pneumogastric or recurrent laryngeal 
nerve may possibly give rise to glottic spasm, but this is doubtless 
an infrequent cause, if it be a cause at all, since these glands are 
often greatly enlarged in strumous and tubercular diseases without 
such a result. According to Dr. Jacobi (iV. Y. Journ. of Med., Jan. 
1860): "In some cases described by Dr. Friedleben, a congenital 
hypertrophy of the thyroid gland has probably been the cause of 
laryngismus. The patients were new-born infants of normal de- 
velopment, and born by normal labors. There were no constitu- 
tional causes of the disease, but a remarkable vascular swelling 
of the thyroid gland. Whenever the swelling increased, the veins 
of the face and head increased in size also, the face grew livid, and 
the extremities and spinal column exhibited slight tonic convul- 
sions. The recurrent nerves were entirely surrounded by the 
glandular tissue, their neurilemma looked unusually red, and their 
functions were probably injured during the occasional swelling 
taking place during lifetime." 

The cause is occasionally located in the cerebro-spinal axis. 
Thus Dr. Coley relates a case in which an exostosis arising from 
the internal surface of the occipital bone pressed upon the cere- 
bellum, while nothing abnormal was discovered in other organs. 
There are also striking examples in which the cause was located 
in the spinal cord. Thus Marshall Hall relates the following case 
communicated to him. A child with spina bifida was attacked 
with croup-like convulsions, whenever it lay so as to press on the 
tumor. 

In some patients there is evidently an hereditary predisposition 
to this disease ; those affected belonging to families in which there 



408 INTERNAL CONVULSIONS. 

is a tendency to convulsive affections. Thus Toogood relates that 
five infants of the same family were affected with spasm of the 
glottis ; and Reid relates, on the authority of Powel, that of thir- 
teen infants of the same parents only one escaped internal convul- 
sions. 

The common predisposing cause is an excitable state of the ner- 
vous system, often associated with impaired general health. Hence 
the disease is more prevalent in cities, where anti-hygienic condi- 
tions abound, than in the country. Hence, too, the frequent im- 
provement when the patient is removed to the pure and bracing 
air of the country. The use of insufficient food, or food of a bad 
quality, must for the same reason be considered a cause, as it leads 
to impoverishment of the blood, and renders the nervous system 
more impressible. Facts mentioned by Reid and others show con- 
clusively the influence of premature weaning, and of indigestible 
or otherwise improper aliment, in the production of this disease. 

The causes enumerated above are for the most part predisposing ; 
occasionally they are the only apparent causes, since this disease 
sometimes occurs when the child is perfectly tranquil, even in the 
midst of quiet sleep, or when it is at rest in its mother's arms. In 
other cases, and more frequently, there is an exciting cause, often 
trivial. Anything that requires exertion on the part of the infant, 
or that excites strong emotions, may be a direct cause, as anger, 
or any of the violent passions ; so may even coughing, or, in rare 
instances, attempts to swallow. One author has known it to occur 
from excitement produced by examining the throat with a spoon. 
In a case in my practice, hereafter related, it occurred whenever 
the infant cried violently. It appears from the above facts that 
the etiology of internal convulsions is very similar to that of eclamp- 
sia. The same spasmodic muscular contraction may occur from a 
variety of causes. 

Anatomical Characters. — While, therefore, structural changes 
in various parts of the system may give rise to internal convulsions, 
this disease, so far as ascertained, presents no anatomical charac- 
ters, and must consequently be considered one of the neuroses. The 
lesions of the respiratory apparatus, observed at post-mortem exami- 
nations, are either due to the convulsions or are coincidences. Em- 
physema has sometimes been observed as a result, it is believed, of 
the spasmodic and irregular respiration. It was present in all of 
Herard's cases, and Rilliet and Barthez consider it common in those 
who die of this affection, although they did not observe it in any 
of their cases. Slight emphysema occurring in the upper lobes is, 



SYMPTOMS. 409 

however, a common lesion in feeble infants, whatever the disease 
of which they die. Therefore its occurrence in internal convul- 
sions is probably more due to molecular change in the lungs, since 
these patients are cachectic, than to the irregular breathing, which 
is only momentary. 

In fatal cases of internal convulsions the blood is darker than 
usual, from an excess of carbonic acid ; the cavities of the heart 
and large vessels are sometimes engorged with blood, but in other 
cases they contain no more than the normal amount. More or 
less passive congestion occurs in the internal organs; and congestion 
of the cerebral vessels is sometimes such that transudation of serum 
occurs. 

Symptoms. — I have said that the symptoms vary according to 
the seat and function of the muscles which are affected. There is 
generally previous ill health. The child is drooping, and is some- 
times restless for clays before the disease appears. Finally, if the 
muscles of the glottis become affected, the peculiar crowing sound 
is heard now and then during inspiration. It is observed espe- 
cially when the child is crying or is agitated. It may be loud 
and well defined from the first, but in most patients it comes on 
gradually, so that several days elapse before its full stridulous 
character is developed. The attacks are more frequent and severe 
at night, in or after the first sleep, than in daytime. 

Under favorable hygienic conditions, the disease may pass off 
without becoming more serious. In other cases the paroxysms 
gradually increase in frequency and severity. The dyspnoea in 
the attack is such that the features are livid, the head forcibly 
retracted, and death seems imminent from apncea. In these severe' 
paroxysms respiration often ceases entirely for a moment. When 
the spasm ends, a deep stridulous inspiration occurs, after which 
the breathing is natural. It has been stated that internal convul- 
sions are often associated with those, usually tonic, but sometimes 
clonic, of the external muscles. In the tonic form, the thumbs are 
flexed across the palms of the hands, and sometimes are grasped 
by the fingers; the great toes are adducted, and the other toes 
flexed. In severe cases, the hands, forearms, feet, and legs are also 
somewhat flexed and rigid. At first, the contraction of the external 
muscles is temporary, either corresponding with the internal spasm, 
or it is most intense at the time of the spasm, though commencing 
sooner and subsiding later. After a while, however, if the dis- 
ease continues, the external contraction becomes more persistent. 
In severe cases, nearly every inspiration is accompanied by the 



410 INTERNAL CONVULSIONS. 

wheezing sound, and the paroxysms of dyspnoea are excited by 
trifling causes. Anything that suddenly disturbs the mind or 
body may bring on the attack, as anger, the impression of cold, 
or currents of air. Dr. West calls attention to the fact that an 
anasarcous condition is sometimes present, accompanied by albu- 
minuria. 

If the convulsions affect other muscles, as the diaphragm or the 
pectoral and abdominal muscles, which are concerned in the 
respiratory function, while those of the larynx escape, respiration 
is irregular, or even suspended for a moment, but the stridulous 
laryngeal sound is absent, as there is no obstacle in the larynx to 
the entrance of air. In this form of the disease, the infra-mam- 
mary region may be strongly retracted during the paroxysm 
from tonic contraction of the diaphragm. In severe paroxysms, 
whether the spasm be laryngeal or diaphragmatic, consciousness 
is nearly or quite lost, the features may be pallid, or, if respiration 
be suspended, may be more or less livid. There is no fever in 
simple cases. In the paroxysm there is often relaxation of the 
sphincters of the bowels and bladder, with involuntary evacuations. 

The duration of the paroxysm may be a quarter, a half, or even 
a whole minute. Total suspension of respiration for even half a 
minute involves danger. In mild cases there may be but few 
paroxysms, and they slight. In other instances they occur in a 
severe form, almost daily for several weeks or even months. In 
the following case the muscles of the larynx were apparently not 
involved. The patient was scrofulous, and has since had scrofulous 
periostitis, with necrosis and exfoliation of the surface of the tibia. 
At the time of the internal convulsions there was also a scorbutic 
or hemorrhagic cachexia. 

Case. — On the 28th of August, 1858, a German female infant, four- 
teen months old, nursing, and having eight teeth, was suddenly seized 
with clonic convulsions. Uniformly delicate and pale, she had been in 
her usual health till the age of twelve months, when she had a single 
convulsive attack, and from that date had remained well till August 27, 
when, without any premonitory symptom, she had a stool consisting of 
almost pure blood, black and offensive. On the morning of the 28th a 
similar evacuation occurred, and another in the afternoon immediately 
preceding the convulsion. Pulse 128, after the convulsion ; surface 
cool and pallid; flesh soft, but no emaciation. Turpentine was prescribed 
in two-drop doses every two hours, and laudanum in one and a half drop 
doses repeated sufficiently to insure quietude. 

On the 29th the pulse was 152. At 1 P.M. she had a general convulsion, 
lasting about five minutes ; in the evening she had an evacuation 
similar to those passed on the preceding day. The record for August 
30 states: "Pulse from 150 to 160; up to this time has been playful, 



DIAGNOSIS — PROGNOSIS. 411 

but is now drowsy, and, when disturbed, fretful; manifests no desire 
for solid food, as before her sickness, but still nurses ; has taken up 
to this time thirty-two drops of turpentine. When she cries or frets, 
she has a spasmodic attack." This was the commencement of internal 
convulsions, with which this child was affected for several months. An 
opportunity was afforded of observing their character, for her excite- 
ment, when she was examined, was usually sufficient to produce them. 
After a succession of short expirations, respiration ceased ; for a 
moment she was apparently insensible; eyes closed; face pale; no 
frothing at the mouth. The return of consciousness and respiration was 
without an} T laryngeal rale ; and after the attack she seemed as well as 
before. Xo external convulsion and no evacuation of blood occurred 
after August 31. 

There was gradual improvement in her health, but she continued 
for man} T months pallid and irritable, and subject to attacks of internal 
convulsions. On the 11th of April, 1859, when twenty-two months 
old, she had another attack of general convulsions. The record made 
on that da}' is: u Has had internal convulsions (one or more parox3~sms) 
almost every da} r since last August, brought on usually by ciying when 
she is corrected in any way, or her wishes are refused." Again, on Dec. 
1, 1859, it is stated : "Has growm considerably since the last record, and 
appears to have recovered, except that at long intervals the spasms still 
occur." She took a preparation of iron, but her recover seemed to be 
due more to the growth and development of the bod}', and to hygienic 
than therapeutic measures. 

The general health in internal convulsions is more or less im- 
paired, except in mild forms of the disease, in which the convul- 
sive attacks soon cease. Pallor, or a sickly and cachectic aspect, 
irregular, usually constipated bowels, poor appetite, and morose- 
ness or irritability of temper, are common symptoms of severe and 
protracted cases. 

Diagnosis. — This disease is easily diagnosticated, unless when 
its symptoms are masked by those of external convulsions ; it may 
then escape notice. Spasm of the glottis may be mistaken for 
spasmodic laryngitis, and vice versa. In some of the published 
cases this mistake appears to have been made. Spasmodic laryngitis 
is, however, so different not only in its nature, but in its clinical 
history, that a differential diagnosis is not difficult. It is an 
inflammatory disease, and is attended with febrile reaction and a 
sonorous cough ; it commences at night after the first sleep, and 
from exposure to cold — particulars in regard to which it contrasts 
with true spasm of the glottis. 

Prognosis. Modes of Death. — Statistics show great mortality 
in this disease. Dr. Eeid, in a monograph on "Infantile Laryn- 
gismus," states that of 289 cases which he collated, 115 died. 
Killiet and Barthez met with one favorable case in nine unfavorable ; 
and Herard, one in seven. If the paroxysms are mild, infrequent, 



412 INTEKNAL CONVULSIONS. 

and dependent on a cause which can be easily removed, recovery 
is probable with proper treatment. The cause may, however, be 
such, even when the spasm is mild, that the case is necessarily 
unfavorable ; as when it is due to disease of the cerebro-spinal axis. 
We should not, however, in any case consider the patient entirely 
safe, since grave symptoms may suddenly arise, so as to change 
entirely the prognosis. Long and severe paroxysms, with lividity 
of the face, and symptoms of suffocation, indicate an unfavorable 
result. The same should be predicted also if the infant gradually 
waste away, losing appetite and strength, especially if the face is 
pale and the pulse feeble. 

There are three modes of death in internal convulsions. The first 
is apncea. The infant dies suffocated in the attack. Respiration 
is first arrested, and then the pulse ceases, and at the autopsy the 
lungs and the cavities of the heart are found engorged with dark 
blood. Death may also occur from the state of the brain. In such 
cases, passive congestion of the brain occurs from obstruction to the 
return of blood from this organ to the heart and lungs; and if this 
congestion is not soon relieved, serous effusion also occurs. Death 
results from the congestion, and consequent oedema or dropsy. 

The third mode of death is from exhaustion. Repeated and 
severe attacks undermine the constitution ; the infant grows pale 
and thin gradually, and dies of inanition, or of some disease which 
this state induces. 

Treatment. — The treatment of internal convulsions has varied 
according to the theories which physicians have held in reference 
to its cause. Glandular enlargement is no longer regarded as a 
common cause, and therefore treatment directed to its removal is 
less frequently employed than formerly. The causes of internal 
convulsions are in part very similar to those of eclampsia, and the 
remedies employed in the one affection are, in a measure, appro- 
priate in the other. That dentition is sometimes a cause, is usually 
admitted; and two cases, one of which occurred in my practice, 
and the other was reported to me, clearly show the truth of this 
belief. The effect of dentition is especially observed in weakly 
infants, when several dental follicles are undergoing; active evolu- 
tion. Thus, in one of the cases to which I refer, five teeth pierced 
the gums in the course of two weeks ; after which no convulsive 
attack occurred. If, therefore, the gums are swollen, scarification 
is proper. 

In all cases of internal convulsions a careful examination should 
be made, in order to detect any appreciable cause of nervous exci- 



TREATMENT. 413 

tation. The condition of the digestive organs should he ascertained, 
and evacuants or other remedies prescribed if there is evidence of 
their derangement. 

Sometimes the alimentation of the infant is in fault. It is, 
perhaps, bottle-fed, and the stools have an unhealthy appearance. 
Attention should he given to the preparation of its food and the 
times of its feeding ; or, if it nurse, the mother or wet-nurse who 
suckles it should have plain but nutritious diet, live with regu- 
larity, and give the breast to the infant at regular intervals. If 
there is a torpid state of the bowels, Dr. Meigs recommends 
"castor oil and aromatic syrup of rhubarb rubbed up together, 
three parts of the former and five of the latter." A simple enema 
answers well in such cases, and, in debilitated infants, this is 
preferable to medicine administered by the mouth. If there be 
diarrhoea, and it persist after the requisite changes are made in 
regard to the diet, remedies calculated to relieve it, and which are 
detailed elsewhere, should be employed. Marshall Hall states 
that he has ordinarily succeeded in curing the disease by attending 
to the condition of the gums and digestive organs. 

In pallid and cachectic infants, tonics are required. The elixir 
of Calisaya bark in half-teaspoonful doses, three or four times 
daily, to an infant of one year, is an eligible preparation. The 
compound tincture of bark, or of gentian, or the two mixed, may 
be given instead of the Calisaya bark. The preparations of iron 
are sometimes to be preferred. The best of these are the syrup 
of iodide of iron, tincture of iron, or the wine of iron. To an 
infant of one year the syrup may be given in doses of four drops, 
the tincture of two drops, and the wine in doses of one teaspoonful, 
three times daily. If the child is old enough, it may take iron in 
lozenges, as those of chocolate and iron. 

Antispasmodics, as assafcetida, valerian, and oxide of zinc, are 
often prescribed in this disease, but they are less efficacious than 
the general tonic measures which I have indicated. The salutary 
effect of bromide of potassium in eclampsia, and certain epilepti- 
form attacks, certainly justifies the trial of this agent in internal 
convulsions, if they persist after the employment of invigorating 
measures. 

Hygienic measures are of the utmost importance. The infant 
should reside in dry and airy apartments, and should be kept much 
of the time through the day in the open air. Eemarkable success 
sometimes attends this simple expedient, when medicines have 
entirely failed. In the London Med. Gazette, Jan. 14, 1865, Mr. 



414: INTERNAL CONVULSIONS. 

Robertson, of Manchester, relates five severe cases in which this 
disease was cured by exposure of the infants several hours daily 
to a cool atmosphere. These cases were treated in the winter 
months, and were kept out-door, even during strong winds. Mr. 
Robertson has records of forty cases, all occurring between Decem- 
ber and April, while he has seen no case in the summer months. 
As the result of such extensive experience, this writer recommends 
"the free exposure of the infant out of doors, for many hours 
daily, to a dry, cold atmosphere, and if the air be dry, the colder 
the better." Dr. Marshall Hall's experience was similar. Says 
he : " The curative influence of change of air, and especially of the 
sea-breezes, is not less marked in this affection than in hooping- 
cough." Mr. Robertson recommends also, as part of the tonic 
treatment, "free sponging of the body every morning with cold 
water." In February, 1867, I attended a nursing infant, five 
months old, with internal convulsions, the paroxysms being 
attended with lividity of the face, and, at times, tonic convulsions 
of the limbs. Among the remedies employed was bromide of 
potassium, but more benefit obviously accrued from keeping the 
infant much of the time in the open air, than from the medicines 
employed. The disease passed off in six or eight weeks. 

Unless the cause is of such nature that it cannot be removed, 
the above hygienic and therapeutic measures will, in a large pro- 
portion of cases, be followed by a satisfactory result. 

The mother or nurse may abridge the paroxysm by raising the 
infant, blowing upon it, sprinkling water in the face, or gently 
stroking it. Dr. Hall recommends tickling the nostrils with a 
feather, to produce respiration, or the fauces, to occasion vomiting, 
and thereby interrupt the paroxysm. Anything which produces 
a sudden and profound effect upon the system may abridge the 
attack. This was effected in one case, in the practice of Dr. C. D. 
Meigs, by applying a cloth wrapped around ice over the epigastrium 
and the lower part of the sternum. The chief danger during the 
attack is from congestion of the brain, with effusion of serum or 
extravasation of blood. If the attack is severe, and the features 
congested, so that there is evident danger of such a result, cold 
applications should be made to the head, derivatives used for the 
extremities — as sinapisms, or mustard foot-baths — and the bowels 
should be speedily opened by enemata. 



CHOREA. 415 



CHAPTER XIV. 

CHOREA. 

Chorea, or St. Vitus' or St. Guy's dance, is a nervous affection, 
which is characterized by irregular and involuntary muscular 
movements, without loss of consciousness. The movements occur 
in the muscles of volition, and there is probably no one of them 
that may not be engaged, though some are more frequently affected 
than others. It is not known that any involuntary muscle is ever 
involved, though Sir "William Jenner has expressed the opinion 
that occasionally the papillary muscles of the heart are, so that, by 
their spasmodic contractions, they produce insufficiency of the 
mitral valve. This, according to him, affords explanation of the 
fact that, in certain instances, a mitral regurgitant murmur is 
heard, which disappears about the time that the external movements 
cease. It is rare, however, that a mitral regurgitant murmur, 
heard during chorea, ceases when the latter terminates, and it is 
not improbable that in such cases there is, after all, a lesion of the 
valve, due to recent endocarditis, whether of a rheumatic or other 
origin. Tor a valve may be so thickened by recent inflammation 
as to cause a murmur, and after a few weeks or months the infil- 
trating substance be so absorbed that the murmur is no longer 
audible. If we admit the fact that cardiac bruits occasionally 
appear and disappear with chorea, this explanation seems to me 
more plausible than that of Jenner. Hillier says, in reference to 
this subject : " My own experience leads me to doubt the existence 
of dynamic apex murmurs in chorea, that is to say, murmurs pro- 
duced in hearts entirely free from organic change. If such murmurs 
ever occur, they are certainly rare. Organic murmurs of the heart, 
on the other hand, are common in chorea, and I am inclined to 
believe that organic disease of the heart often exists in chorea 
when there is no murmur." Hillier also calls attention to the fact 
that choreic movements are irregular ; but a cardiac bruit occur- 
ring regularly and uniformly, if not due to organic disease, would 
require rhythmical contractions of the papillary muscles to pro- 
duce it. 





6 years 
and under. 


6 to 10 

years. 


10 to 15 
years. 


London, Hillier 


. 81 


237 


104i 




. 10 


61 


118 


it, Belle vue . 


. 2 


26 


16 



416 CHOREA. 

Age. — Chorea may occur at any period of life ; but while it is 
comparatively rare at other ages, it is not infrequent in childhood. 
A large majority of cases are between the fifth year and puberty. 
Under the age of five years, the proportionate number diminishes 
as we approach the time of birth, and it is rarely observed in in- 
fants under one year. The youngest in the statistics of Hillier was 
three months. 

In 1870, at the Out-door Department of Bellevue, a child was 
presented for treatment, who, the mother stated, had had chorea 
from birth. The choreic movements were no doubt observed very 
early in infancy, though the disease probably was not congenital. 
The following table exhibits the relative frequency of chorea at 
different ages during infancy and childhood : — 



Children's Hospital, 

M. Rufz 

Out-door Departme 

M. See collected the statistics of 531 cases occurring in the 
Children's Hospital, Paris, and from them concludes that the maxi- 
mum frequency of chorea is between the sixth and tenth years. 
Only twenty -eight of his cases were under six years, the remainder, 
503, occurring between the sixth year and puberty. 

Causes. — The profession are nearly agreed in regard to certain 
causes of chorea, while there is a diversity of opinion in reference 
to others. It is admitted that in a large proportion of cases there 
is a neuropathic state, which antedates and predisposes to chorea. 
This state is often manifested in the family history by a proneness 
to affections of the nervous system, and in the individual by a 
highly excitable state of the emotions, so that he evinces joy, grief, 
or anger, from slight causes. 

All writers admit that there is often an inherited predisposition 
to chorea. In 27 of 48 cases of chorea, Radcliffe found that father, 
mother, brother, or sister had been or was the subject of one or 
other of the following disorders : paralysis, epilepsy, apoplexy, hys- 
teria, or insanity. The children of parents who when young had 
chorea, or who exhibit proneness to ailments of the nervous system, 
are more liable to chorea than other children. Hence the fact 
sometimes observed, of different children in the same family be- 
coming affected with chorea when they attain the age at which 
this disease ordinarily occurs. In one family, in my practice, 
three girls at different times were affected. 

1 None over 12 years admitted. 



SEX — ANJEMIA. 417 

Sex. — The emotions are strong in girls, since in them the 
nervous system predominates, while the muscular power is weaker 
than in boys. Hence a partial explanation of the fact which 
statistics fully establish, that the proportion of choreic boys to 
girls is about in the ratio of one to two and a fraction. I have 
remarked, in this city, the large proportion of cases in school-girls 
between the ages of six and twelve years ; the severe discipline 
and confinement of the public schools no doubt increasing the 
strength of the emotions, and weakening the control of the will 
over the muscles. 

Proyortion of Males to Females. 

27 to 73. Hughes' Digest of Cases in Guy's Hosp., 1846. 

138 to 393. M. See. 

25 to 40. Out-door Department, Bellevue. 

276 to 499. Children's Hosp., Lond. West (Lumleian Lect.). 

466 to 1005 =1 to 2.15. 

Uterine Irritation. — The peculiar changes occurring in the 
female at puberty constitute an important cause. Hence another 
reason of the excess of female cases. Dysmenorrhea and preg- 
nancy are causes of a large proportion of cases in the first years of 
puberty. In the male, on the other hand, the changes of puberty 
do not appear to increase the liability to the disease, directly or 
indirectly, and male cases, after the age of twelve years, are com- 
paratively rare. Radcliffe states (Reynolds' System of Med.) that 
after the ninth year, females are more liable to chorea than males, 
in the proportion of 5 to 2 ; while before the ninth year, the two 
sexes are equally liable to it. Carefully prepared statistics, how- 
ever, notwithstanding the high authority of RadclifTe, show a 
preponderance of girls under the age of nine years, though not as 
great as over that age. In the Out-door Department at Bellevue, 
of 35 patients under the age of ten years, 22 were girls, while of 
20 from the age of ten years to sixteen, 15 were girls. 

According to West (Lumleian Lect.), in 775 children with' chorea, 
under the age of ten years, treated in the Lond. Children's Hosp., 
64 per cent, were girls. 

Anemia. — Among the most common predisposing causes of 
chorea is ansemia. It is present in so large a proportion of cases, 
exhibiting itself by pallor of the countenance and other character- 
istic sigus, that medicines designed to improve the quality of the 
blood are among the most valued remedies. The peculiar neuro- 
pathic state already alluded to, which needs only a slight additional 
27 



418 CHOREA. 

cause for the development of chorea, is, no doubt, largely depen- 
dent on impoverishment of the blood, if it is not sometimes due 
entirely to it. Among the poor of a large city like New York, or 
in hospital practice, the proportion of aneemic cases of chorea is, 
for obvious reasons, much larger than would appear from general 
statistics. 

Rheumatism. — Dr. Copland, M. Bouteille, and afterwards M. 
Germain See, in a more extended monograph, directed the atten- 
tion of the profession to rheumatism as a cause of chorea. Subse- 
quent observations have established the fact that rheumatism, or 
the rheumatic diathesis, is so frequently present that it obviously 
sustains an important relation to chorea, though in what manner is 
not fully ascertained. This relation between the two is more fre- 
quently observed in some countries than in others. In England and 
France, so large a proportion of choreic patients present the history 
of rheumatism either in themselves or family, that certain phy- 
sicians of these countries believe that rheumatism is the most 
common cause of the disease. In Germany, on the other hand, 
according to Romberg, in the majority of cases no relation can be 
traced between chorea and rheumatism, and the statistics of this 
city, and I think of this country, correspond with those in Ger- 
many. 

Various theories have been promulgated in explanation of the 
relationship of the rheumatic and choreic diseases. It has been 
suggested that chorea is due to rheumatism of the brain or spinal 
cord. This is simply an hypothesis, the truth or falsity of which 
can only be ascertained by carefully conducted necropsies ; but the 
theory appears improbable in view of all the facts. Another theory 
attributes chorea to the state of the blood which is present in those 
having rheumatism or the rheumatic diathesis, as well as in cer- 
tain other conditions. This theory is enunciated by Dr. Ogle, as 
follows : " Recognizing the frequent existence of these fibrinous 
deposits or granulations on the heart's valves in chorea, I should 
be much inclined to look upon these post-mortem appearances 
rather as results of some antecedent general condition of the blood, 
common also to the choreic condition. It is very freely recognized 
that this affection is frequently, in some way or other, connected 
with that condition of blood which obtains in what we call anemia, 
or that existing in rheumatic constitutions. In both of these 
states we know that the fibrin of the blood is much in excess (as 
also it is in pregnancy, another condition looked upon as obnoxious 
to chorea) ; and in these states we know that the fibrin with which 



RHEUMATISM. 419 

the blood is surcharged is very prone to be readily precipitated, 
either owing to its superabundance, or from other obscure and 
acquired properties . . . upon the heart's walls or valves. May 
not this hyperinosis be the explanation of the coincidence alluded 
to?" {British and Foreign Med.-Chir. Rev., January, 1868) — namely, 
the occurrence of chorea in those affected with rheumatism. Others 
still hold that chorea is the result of the heart disease, and not 
directly of rheumatism, occurring when the heart is affected from 
other causes, as well as when the lesion has a rheumatic origin. 
This theory is plausible, and probably to a certain extent correct. 
Heart lesions, observed in children, result from scarlet fever in a 
considerable proportion of cases, though, it is true, the endocarditis 
and pericarditis of scarlet fever are believed often to have a rheu- 
matic origin, occurring, in some instances, from scarlatinous rheu- 
matism, but in other cases from scarlatinous uraemia. Occasionally 
also the heart disease appears to have occurred independently of 
both rheumatism and scarlet fever. Thus in a fatal case of chorea 
with valvular disease, related to the Lond. Path. Soc, April 6, 
1869, the child was always healthy up to the present illness (chorea), 
and there was no history of rheumatism in the family. The more 
observations accumulate, the more important does heart disease in 
itself appear as a cause of chorea. In nearly all recorded cases of 
fatal chorea, which were supposed to be due to rheumatism, and in 
which post-mortem examinations were made, vegetations have 
been discovered upon the valves — aortic or mitral. We shall see 
that certain eccentric causes of irritation aid in producing chorea, 
and may not the valvular disease, or the endocarditis which causes 
the valvular lesion, operate in a similar manner as a cause ? We 
know that in the adult severe cardiac disease often profoundly 
affects the nervous system, perhaps in consequence of the irregular 
and embarrassed circulation ; and certainly in the child a similar 
cause would be likely to produce a more decided effect. 

But there is an ingenious theory which attributes chorea to 
minute emboli detaehed from vegetations on the valves, and 
arrested by capillaries in the corpora striata, or other portion of 
the cerebro-spinal axis. Since attention was directed to this 
matter, emboli have been found in one case in the medulla oblon- 
gata, although this portion of the spinal axis appeared healthy to 
the naked eye. Further observations are necessary in order to 
determine how much truth there is in this theory ; but it seems 
probable, for reasons to be stated, that if capillary embolism does 
cause chorea, it is only in a limited number of cases, and that 



420 CHOEEA. 

therefore those British observers who regard it as the common 
cause, have been led into error by the large proportion of choreic 
cases which are complicated by valvular lesions in their climate. 

That embolism is not a common cause, if indeed a cause at all, 
appears probable from the following facts: First. In many cases 
of chorea there are no vegetations, or other appreciable lesion, 
which could give rise to emboli. Secondly. Most patients recover, 
and some speedily, by treatment, which we would not expect if 
the cause were embolism. Thirdly. Embolism is not infrequent 
in the cerebral vessels of the adult, without the occurrence of 
chorea. Indeed, the conditions which produce embolism are much 
more common in adults than in children, while the reverse is true 
as regards the liability to chorea. Fourthly. Dogs sometimes 
have chorea, but the injection of minutely divided fibrin or other 
substance in the veins of the dogs is not followed by chorea as one 
of the phenomena. Fifthly. "Were capillary emboli the cause, we 
would expect to find an occasional embolus in the larger vessels 
of the brain, so as to be appreciable to the naked eye ; but I find 
no examples of this in all the recorded autopsies which I have 
been able to consult. Moreover, it seems improbable that capillary 
embolism, when producing no lesion appreciable to the naked eye, 
would so arrest the circulation, and disturb the function of the 
brain or spinal cord, as to cause chorea, for the ill effects of such 
an obstruction would be likely to be obviated by the numerous 
anastomoses. 

It is obviously better, in the present state of uncertainty regard- 
ing the exact relation of rheumatism and valvular disease to chorea, 
to postpone the acceptance of any theory till the minute anatomy 
of chorea has been as fully investigated as has its clinical history. 

Fright. — A not infrequent exciting cause of chorea is sudden 
and profound emotion, especially fright. All statistics give fright 
as the cause of a certain proportion of cases, though there are 
usually other potential co-operating causes, as anaemia or valvular 
disease. Fright was stated as the cause of chorea in 31 of the 
100 cases occurring in Guy's Hospital, reported by Hughes, or in 
nearly one in three. But the statistics of other observers do not 
give so large a proportion of cases originating in this way. Chorea 
may commence within a few hours after the fright, or not till the 
lapse of several days (eight or ten). If several weeks have passed 
since the fright, as in some reported cases, the chorea is probably 
due to other causes. In rare instances, chorea is said to have been 
caused by sudden and excessive joy. 



INTESTINAL IRRITATION. 421 

Imitation. — Under unusual circumstances, especially in a state 
of great mental excitement, imitation has been known to cause a 
form of chorea. Hecker describes an epidemic of it, occurring in 
the middle ages, and spreading through villages. In modern 
times it is rare that chorea originates from this cause, nevertheless 
occasional examples have been recorded. 

But the disease which occurs from imitation differs from the 
ordinary form, and has been termed chorea major; while chorea 
proper, which is the subject of this article, is sometimes designated, 
in contradistinction, chorea minor. 

In chorea major, the patient leaps, dances, or whirls like a top. 
It has its origin commonly in religious excitement, and spreads by 
imitation almost in the manner of an infectious disease. The 
epidemic of the middle ages was a chorea major. I have not been 
able to find any account of cases spreading by imitation, in modern 
times, which were not examples of the same form of chorea. Thus 
in the Edin. Journ. of Med. and Surg, for July, 1839, there is a 
clear description of chorea major, occurring successively in five 
children in the same family. Dr. Dewar, the attending physician, 
states that one of the children whom he was called to see was 
sitting near the fireplace, when her head dropped on her chest, 
and she appeared to doze some minutes. In the meantime the 
respiration became a little accelerated, the face altered and flushed, 
the eyes wild. In less than one minute she bounded from one 
extremity of the apartment to the other, leaping over chairs, a 
chest, and then throwing herself upon the floor ; she attempted to 
stand upon her head, rolled upon the floor, and then, rising, ran 
with extreme swiftness in the room, till she finally fell again on 
the floor, where she remained motionless some minutes. Then, 
recovering, she noticed those who surrounded her, and asked of 
her sister a toy, which she had allowed to fall. The whole 
paroxysm lasted twenty minutes. 

Obviously, the symptoms of chorea major differ materially from 
those of chorea proper, and it is a. question whether it should have 
the same generic name. It is a curious and interesting disease in 
its psychical and pathological aspects, but it is so rare in modern 
times that a knowledge of it is of little practical importance. 

Intestinal Irritation. — In rare instances intestinal worms cause 
chorea, though in these cases there have usually been some co- 
operating causes. The following is an example, related by Mr. 
Ogle (Lond. Medico-Chir. Rev., Jan. 1868): Ellen L., 9 years old, 
had been under treatment about a month with chorea, rheumatism, 



422 CHOREA. 

and worms. She had not slept in four days, and there was constant 
spasmodic movement of the body and face. Her general condition 
was very unpromising. As she had passed portions of a tapeworm 
at intervals during the last three months, one drachm of the oleum 
filicis maris was administered in mucilage, which caused the 
expulsion of the entire worm. From that time she fully and 
rapidly recovered from the chorea, though a mitral murmur 
remained. 

Lesions of Brain and Spinal Cord. — Nearly all standard authors 
who reject embolism as a cause of chorea, believe there is no 
anatomical cause of the disease located in the cerebro-spinal axis. 
In other words, they regard chorea as one of the neuroses. This 
view is probably, in the main, correct ; but experiments, and also 
occasional cases, establish the fact that if not true chorea, at least 
choreiform movements, now and then result from a structural 
affection of the nervous centres. 

Experiments on certain of the lower animals demonstrate that 
irregular muscular movements may be produced by traumatic 
injury of certain portions of the cerebro-spinal axis, as the corpora 
quaclrigemina, crura cerebri, pons Varolii, crura cerebelli, thalami 
optici, parts of the medulla oblongata, and the upper portion of the 
spinal cord. Pressure on the projecting part of the medulla oblon- 
gata of an acephalous monster also causes convulsive movements. 
At the meeting of the HT. Y. Acad, of Medicine, April 20, 1871, 
Prof. Post related the case of a child who was struck with a billet 
of wood, over the occiput, and chorea followed, due, in all proba- 
bility, to the injury of the brain which resulted. 

If irregular muscular movements, choreic or choreiform, result 
from traumatic injury of certain portions of the nervous centres, 
may they not also occasionally occur from lesions of the same parts 
produced by disease? Sir Benj. Brodie relates the case of a choreic 
girl, dying in St. George's Hospital {London Lancet, Dec. 19, 1840), 
in whom, after a careful post-mortem examination, the only morbid 
appearance observed was a tumor the size of a hazelnut, connected 
with the pineal gland. Dr. Broaclbent described another case be- 
fore the London Pathological Society (vol. xiii., page 246, Tra?}S- 
actions), in which a tumor was found arising from the centre of the 
spinal cord ; and Chambers one in which tubercles were imbedded 
in the cord. Romberg quotes from Frerichs a case in which the 
medulla oblongata was pressed upon by an enlarged odontoid pro- 
cess ; and Dr. Aitken (Glasgow Med. Journ., vol. i.) one in which 
the specific gravity of the thalamus opticus and corpus striatum 



ANATOMICAL CHARACTERS. 423 

was greater on one side than on the other. Killiet and Barthez 
relate other similar cases, and add: " We may conclude, from these 
different cases, that there exist two species of chorea : the one 
essentially a simple neurosis, while the other depends on an altera- 
tion of the encephalo-rachidian system. In a word, it is of chorea 
as of convulsions, that it is sometimes idiopathic, sometimes symp- 
tomatic." Still, the cases in which it is symptomatic are so few, 
that it is proper to consider chorea, as it ordinarily occurs, one of 
the neuroses until the microscope detects some anatomical cause 
in the cerebro-spinal system of which we are now ignorant. 

Anatomical Characters. — So far as ascertained, chorea has no 
certain anatomical characters. As we have seen, lesions are some- 
times present which probably sustain a causative relation to the 
disordered muscular action, and others are sometimes observed 
which are neither a cause nor result, their presence being a coinci- 
dence. But there are two lesions which, though often absent, 
have been observed in so large a proportion of fatal cases that they 
are justly regarded as an occasional result when chorea is severe. 
Dr. Hughes, of London, collected records of the post-mortem ap- 
pearances of 14 cases, with the following result as regards the 
cerebro-spinal axis : Brain, 14 cases : healthy, 4 cases ; only con- 
gested, 3 cases ; softened in part or entirely, 6 cases (some of these 
also congested). In some of these cases those occasional results of 
congestion, namely, transudation of serum and extravasation of 
blood, in greater or less quantity, were also observed. Spinal cord : 
healthy, 3 cases ; congested, 2 cases (one slightly, in the other the 
engorged vessels were large and numerous) ; softening in medulla 
oblongata, 1 case ; softening opposite fourth and fifth vertebra?, 12 
cases. In one there was soft, in another firm adhesion of the spi- 
nal meninges, and in one it is stated that the rachidian fluid was 
opaque. Of sixteen fatal cases of chorea occurring in St. George's 
Hospital, " congestion (more or less complete) of the nervous cen- 
tres (brain or spinal cord, or both) was met with in six cases." 
There was softening of certain parts of the brain in one case, and 
of the spinal cord in another. (Ogle, Brit, and For. Medico-Chir. Rev., 
Jan. 1868.) Other statistics of the anatomical character of fatal 
chorea correspond, in the main, with those of Hughes and Ogle. 
These lesions are probably not present in ordinary cases, occurring 
only when the choreic movements are so severe that the patient is 
deprived of needed repose, and the important functions of the 
economy, as the circulation and nutrition, are seriously disturbed. 

The post-mortem examination of other parts besides the cerebro- 



424 CHOREA. 

spinal axis furnishes a negative result, if we except such affections 
as have been ascertained to act as causes of chorea. What portion 
of the nervous centre is chiefly involved in chorea is uncertain. 
Some, as Sir Benj. C. Brodie {London Lancet, Dec. 19,1840), con- 
sider chorea a disease of the nervous system generally, while others 
have attributed it to disease or disorder of a certain part, as the 
corpus striatum, cerebellum, etc. Finally, it is stated that, in 
late experiments on choreic dogs, the movements do not cease 
when the spinal cord is severed from the brain, nor also on division 
of the posterior roots of the spinal nerves. (Legros et Onimus, Rech. 
sur les mouvements choreiformes du chien, Acad, des Sci.,9 Mai, 
1870, Lyons Med. Journ., June 5, 1870.) In these cases, therefore, 
the part of the axis which is in fault would appear to be solely the 
spinal cord. 

Symptoms. — Chorea is partial or general. It is partial when it 
affects a few muscles, or groups of muscles, as those of one arm, 
the face or neck, or of one eye. It is designated general, when all 
the limbs, and certain of the muscles of the face and trunk, are 
involved. Statistics show that partial chorea occurs more fre- 
quently on the left than on the right side, and in general chorea 
the movements on the left side are apt to predominate. The com- 
mencement is usually gradual. Even when finally chorea becomes 
general, certain muscles only are affected in the commencement in 
ordinary cases. The child in whom this disease is about to begin 
is observed to be fretful and impatient from slight causes, and the 
irregular muscular action at first is apt to be misunderstood by the 
parents, who reprimand him for his supposed fidgety habit. In 
exceptional instances, especially when the cause is a sudden and 
profound emotion, the commencement is abrupt, and the disease is 
severe and general from the first. 

In a majority of cases the muscles which are primarily affected 
are those of the face, neck, fingers, or hand on the left side. 
Sydenham erred, unless the clinical history of chorea has changed 
during the last two centuries, when he stated as the common fact 
that a tottering gait is its first manifestation ; but now and then 
such a case does occur. "Wherever the choreic movements first 
appear, other muscles are soon involved, so that in the course of a 
few weeks, sometimes of a few days, all the muscles that partici- 
pate are engaged. 

A muscle affected by chorea alternately contracts and relaxes, 
but less forcibly and rapidly than in eclampsia, and the movement 
is partly controlled by volition. This produces an unsteady and 



SYMPTOMS. 425 

tremulous action of the part, whether a limb, the neck, or face ; 
which at once arrests attention, and indicates the nature of the 
disease. The result is similar, as regards the muscular action, 
whether the patient wills a movement, or attempts to control those 
which chorea produces. 

If the case is of ordinary severity, the movements continue with 
but momentary intermissions, except during sleep, when they 
ordinarily cease. In grave cases patients are often deprived of the 
proper amount of sleep in consequence of the severity and per- 
sistence of the muscular action, and in exceptional instances, 
especially when the result is fatal, the movements continue in 
sleep, but the sleep is not sound, and is frequently interrupted. In 
profound sleep, the muscles are probably always in repose. 

The older writers have left us graphic descriptions of those 
diseases which have striking external manifestations, though often 
with somewhat of exaggeration. Sydenham says of chorea: "The 
patient cannot keep it (his hand) a moment in the same place; 
whether he lay it upon his breast, or any other part of the body, 
do what he may, it will be jerked elsewhere convulsively. If any 
vessel filled with drink be put into his hand, before it reaches his 
mouth, he will exhibit a thousand gesticulations, like a mounte- 
bank. He holds the cup out straight, as if to move it to his 
mouth, but has his hand carried elsewhere by sudden jerks. Then 
perhaps he contrives to bring it to his mouth, and if so, he will 
drink the liquid off at a gulp, just as if he were trying to amuse 
the spectators by his antics !" 

In severe general chorea a similar description is applicable to the 
movements of the legs and features. Grimaces and distortions of 
the features occur, while the gait is halting and unsteady, or it is 
impossible to walk, and the patient lies or sits. The speech is 
slow, thick, and indistinct, in consequence of the muscles of the 
tongue and larynx becoming engaged, and even mastication and 
deglutition are rendered difficult. The imperfect speech in chorea 
is attributed partly, however, to the impairment of the mental 
faculties. Chorea, except in mild cases, is accompanied by other 
symptoms referable to the nervous system. More or less impair- 
ment of the mental faculties occurs in severe and protracted chorea, 
exhibiting itself in dulness or apathy. The countenance sometimes 
presents in aggravated cases almost the appearance of idiocy. The 
muscles, instead of becoming hypertrophiecl, and more powerful by 
their frequent contraction, grow softer, more flabby, and weaker. 
Indeed, a partial paralysis sometimes results, so that a degree of 



426 CHOEEA. 

numbness is experienced in the affected part, and the limb when 
raised cannot be sustained. Pain is not a symptom of chorea, but 
fugitive rheumatic or neuralgic pains are sometimes experienced. 
Derangement of the digestive function, exhibited by a poor or 
capricious appetite, constipation, etc., are common. 

The urine of choreic patients has been examined by Drs. Walsh, 
Ford, Bence Jones, Handfield Jones, Kadcliffe, and others, and its 
elements have been found in most cases to vary from their normal 
quantity. Dr. Handfield Jones read a paper before the Clinical 
Society of London, in 1871 {London Lancet, July, 1871), on two 
cases of chorea in which he had made careful chemical analysis of 
the urine, with the following result: During the height of the 
disease the amount of the urine was much in excess of what it was 
when the disease had ceased; .the amount of urea excreted during 
the choreic period was enormous ; the amount of phosphoric acid 
excreted when the choreic symptoms were at their maximum was 
excessive, but the quantity was less than the average during con- 
valescence ; a moderate amount of uric acid during the disease, but 
none upon recovery. 

Prognosis ; Course. — Chorea, though obstinate and often incura- 
ble in adults, usually terminates favorably in children in three or 
four months. Bouchut considers its ordinary duration at from 
thirty to fifty days, which is certainly shorter than the average 
duration in this country, except as the disease is materially 
abridged by treatment. The same author states that it may con- 
tinue only twenty-four hours, or some days, as he has observed in 
the convalescence from scarlet fever. But tremulousness of the 
muscles occurring in the state of weakness following a grave 
disease, and abating as the general health is restored, I should not 
consider as properly choreic, any more than that occurring from 
over-fatigue. As the choreic movements gradually increase in the 
initial period till a certain maximum is reached, so their decline 
is gradual. There are temporary variations also throughout the 
disease as regards the extent of the movement, which are aggra- 
vated by mental excitement, bodily fatigue, certain functional 
derangements, especially of digestion, and sometimes from causes 
which are not apparent. 

Though, as a rule, chorea in children ordinarily terminates 
favorably under different, and even injurious, modes of treatment, 
there are exceptional cases. Romberg relates the history of a 
patient who died at the age of seventy-six years, having had chorea 
since the age of six years. In chorea limited to a few muscles, or 



DIAGNOSIS. 427 

a group of muscles, the prognosis is more doubtful than when it 
affects a large number, since in the former case the cause is more 
apt to be some lesion of the cerebro-spinal axis. Thus chorea 
involving only certain muscles of the neck or of the eyes is some- 
times due to this cause, and is then very obstinate. 

Again, observations demonstrate that chorea, when at first in 
all probability strictly a neurosis, but of a protracted and grave 
character, may give rise to a central organic disease. This is the 
course of most of the fatal cases, congestion, softening, or other 
lesion occurring over a greater or less extent of the nervous centres. 
Radcliffe has known cerebral meningitis to supervene in two 
instances. .With the occurrence of a lesion of the cerebro-spinal 
axis, new symptoms arise, such as headache, convulsions, delirium, 
and paralysis, and the choreic movements cease or continue, accord- 
ing to the nature of the lesion. 

Chorea, like certain other diseases, either of a nervous character, 
or having a nervous element, is more or less modified by intercur- 
rent inflammatory and febrile affections. The oft-quoted expres- 
sion from Hippocrates, febris accedens solvit spasmos, observations 
show to be founded in fact, the most frequent example of which 
occurs in pertussis. In chorea the movements, as a rule, are either 
rendered milder- or they cease as long as the febrile excitement 
continues; but there are exceptions, and the subsequent course of 
the disease is not modified. 

Diagnosis. — This is not difficult in ordinary cases. The irregular 
movements, with consciousness preserved, enable us to make a 
diagnosis at sight. In its commencement, and when it continues 
in an unusually mild form, chorea might be overlooked by the 
physician, as it often is by the parents, the movements being at- 
tributed to a fidgety habit ; but medical advice is seldom sought 
till the movements are so pronounced that it is impossible to err, 
except through gross ignorance or carelessness. 

It is important to determine when chorea merges in an organic 
disease, and also whether there is a local cause of the chorea. A 
careful and intelligent study of the symptoms and history of the 
case is requisite in order to a correct diagnosis in these particulars. 

Treatment. Regimenal. — As chorea in a large proportion of 
cases occurs in a state of anaemia, and the vital forces are ordi- 
narily more or less reduced, obviously the regimen should be such 
as invigorates the system. Fresh air and out-door exercise, active 
or passive, according to circumstances, with the avoidance of undue 
excitement, are requisite ; and the diet should be nutritious, but 



428 CHOREA. 

plain and unirritating. The various functions should be preserved 
so far as possible in their normal state. In exceptional instances, 
when the choreic movements are violent, the patient should lie in 
bed, and the muscular action, if so constant and excessive as to 
deprive him of the requisite sleep, should be restrained by light 
and well-padded splints. 

Medicinal. — Sometimes among the co-operating causes is one of 
a local nature, which is susceptible of removal, as a carious and 
painful tooth, intestinal worms, etc., and measures calculated to 
effect this are obviously required. Allusion has already been made 
to a case in which the employment of the oleum filicis maris, and 
expulsion of a tapeworm, effected a speedy cure. 

The remedy which has been most employed in chorea, and which 
in consequence of the ansemia is plainly indicated in a large pro- 
portion of cases, is iron. It does not interfere with the employ- 
ment of other remedies which have a more specific effect. Nearly 
all the ferruginous preparations have been prescribed in different 
cases with benefit. RadclifTe, who justly ranks as one of the first 
authorities in nervous diseases, gives the preference to the iodide 
of iron, believing that iodine, as well as iron, exerts a curative 
influence. I have of late inclined to the use of the ammonio- 
citrate, as it is easy of administration in simple syrup, and is well 
tolerated. 

Arsenic, highly extolled by Romberg and others, is a remedy of 
undoubted value. It is conveniently given in Fowler's solution. 
It should be administered in doses of three to five drops three times 
daily, after the meals, as in the treatment of cutaneous or other 
affections. Eadcliffe has administered by subcutaneous injection 
Fowler's solution, diluted with an equal quantity of water, in a 
few cases of obstinate local chorea, with a satisfactory result. An 
adult with choreic movements in one side of the neck of nine 
years' duration was nearly cured by fourteen injections, employed 
at intervals of a few days, the quantity employed being increased 
gradually from three to fourteen minims of the solution. Another 
remedy of undoubted value is strychnia. Trousseau, who prescribed 
it in most cases, and highly extolled it, employed the following 
formula: — 

R. Strychnise sulphat. gr. j. 
Syr. simplic. §ijss. Misce. 

A child of the ordinary age, say ten years, takes at first a tea- 
spoonful twice or three times daily, at uniform intervals, and the 
dose is gradually and cautiously increased until it begins to pro- 



MEDICINAL. 429 

duce physiological effects. Strychnia, when employed to the extent 
of causing some rigidity, is more efficient as a remedy, but smaller 
doses have been found useful. 

Prof. Hammond {Diseases of the Nervous System, page 617) says : 
" My main reliance is on strychnia, which, I think should be given 
in gradually increasing doses, somewhat after the manner recom- 
mended by Trousseau. . . . This plan of treatment certainly shortens 
the duration of the disease very materially, and causes great im- 
provement in the general health of the patient. Sometimes the 
effect is so well marked, and is so immediate, that it is not neces- 
sary to increase the doses to the extent of causing muscular cramps, 
but generally the full therapeutical effect of the drug is not 
obtained till the calf of the leg or the nucha has slight tonic 
spasm. I have never seen the slightest ill-consequence follow this 
mode of treatment, and the doses are increased so gradually that, 
with careful watching, danger need not be apprehended." Dr. 
Hammond has treated thirty -two children with this agent without 
a single failure. 

But as chorea terminates favorably with smaller and safe doses, 
even if the time required is longer, it does not seem proper to re- 
commend its employment to the extent of producing physiological 
effects for general practice. Bouchut, speaking upon this point, 
says : " But, with these precautions, strychnia is extremely danger- 
ous, for I have seen, at the Hopital des Enfants Malades, a young 
girl of thirteen years die in tetanus," produced by an increased 
dose of this drug (article on Chorea). Dr. West, in his Lumleian 
Lectures, also says: "I have seen one instance in which its employ- 
ment, while it failed to benefit a somewhat severe case of chorea, 
was followed by two attacks of violent tetanic convulsions, which 
nearly proved fatal ; " and he adds, " the twitching of the limbs of 
itself prevents our becoming aware of the dose being excessive, and 
a child's inability to describe its sensations deprives us of another." 
For such reasons, Dr. West does not favor the employment of this 
agent. Still, any agent may be given in an overdose, and it is not 
difficult to prescribe strychnia in a dose which will be efficient and 
yet safe for children at the age at which chorea ordinarily occurs. 
I have employed bromide of potassium in a few cases, but with so 
little benefit that I am not inclined to continue its use for this 
disease. Others have not been more successful. However effica- 
cious the bromide may be in epilepsy, it does not appear to be a 
remedy for chorea. 

Cimicifuga, first employed by Jesse Young of this country, is 



430 CHOREA. 

highly esteemed by Philadelphia physicians in the treatment of 
chorea. I have employed the fluid extract in doses of half a drachm, 
increased to one drachm, for a child from six to ten years of age, 
and though it benefits some cases, it has no appreciable effect 
either in moderating the movements or abridging the duration of 
others. 

Ether, assafcetida, valerian, musk, the oxide and sulphide of 
zinc, turpentine, tartar emetic, opium, and numerous other reme- 
dies, have been recommended, and some of them have seemed use- 
ful in certain cases. In this city sulphate of zinc has been frequently 
employed as a remedy for chorea, and in gradually increasing doses 
till more than twenty grains were administered three times daily, 
but it has not appeared, so far as I have been able to ascertain, to 
exert any marked influence either on the severity or duration of 
the choreic movements. Justice, however, requires us to state 
that Dr. West, who has written most recently on the nervous dis- 
orders of children, thinks that it has been beneficial in certain 
cases in which he has employed it, and regards it on the whole as 
the best remedy. 

Radcliffe, who has had ample experience in the treatment of 
nervous affections, writes : " In an ordinary case of chorea the 
plan of treatment which I have now adopted as a rule for some 
time is to give cod-liver oil, in conjunction with hypophosphite of 
soda, making the draught containing the latter salt the vehicle for 
the administration of the cod-liver oil." Sometimes camphor or 
the sesquicarbonate of ammonia is added. Of more than thirty 
cases treated in this way, the average duration was under three 
weeks. Eadcliffe began to prescribe these remedies on theoretical 
grounds, believing that phosphorus and cod-liver oil were re- 
quired to restore " nerve tone," and the result of this treatment 
has certainly been such as to commend it to the profession. To 
children he gives from five to eight grains of the hypophosphite of 
soda three times daily. 

In those severe cases in which the choreic movements prevent 
the proper amount of sleep, a moderate dose of hydrate of chloral 
may occasion ally be advantageously administered. 

Electricity has been many times employed in the treatment of 
chorea, and though some, chiefly electricians, believe that it has a 
curative effect, others, and the majority, fail to see any material 
benefit from its use. 

Cold general baths, the shower-bath, frictions along the spine, 
etc., have been employed ; but the local treatment, which has so 



INFANTILE PAEALYSIS. 431 

far been most successful, and which promises to supersede all others, 
consists in the application of ether spray over the spine. About 
two ounces of ether are employed at each sitting, the spray being 
applied from an atomizer up and down the whole length of the 
spine if the chorea is general. The operation, which occupies 
from ten to fifteen minutes, should be repeated daily or every 
second day. Although this mode of treatment is quite recent, a 
considerable number of cases have already been reported, in which 
the spray has apparently had a very decided effect in controlling 
the disease. 



CHAPTER XV. 

INFANTILE PARALYSIS. 

Paralysis in young children, especially infants, is in most 
instances due to causes which seldom produce it in adults. The 
principal cause of it in the adult, namely, cerebral apoplexy, is 
indeed rare in children. Paralysis in children has the following 
recognized causes: 1st. A change in the blood, not fully under- 
stood, induced by certain grave diseases, as diphtheria, typhoid 
fever, measles, scarlet fever, etc. 2d. Reflex influence. The func- 
tion of some part of the system is in some way disturbed, and 
paralysis occurs in certain muscles, may be at a distance from the 
cause, and it disappears when that cause is removed, unless it has 
continued too long. The only rational explanation is found in the 
fact of a continuous connection between the local causes and the 
paralyzed muscles through the afferent and efferent nerves, and 
the nervous centres. 3d. An anatomical alteration in the muscular 
fibres, the nerves and nervous centres remaining unaffected. This 
has been designated myogenic paralysis. This form of paralysis is 
probably often of a rheumatic nature. We see a similar disease in 
that form of facial paralysis of the adult which results from long 
exposure of the face to a cold wind. 4th. A cause seated in the 
nervous system, either congestion, hemorrhage, softening, or com- 
pression, whether from inflammatory products or other cause. 

Paralysis occurring as a symptom, or sequel of some obvious 
local or general disease, as diphtheria, lesion of the nervous centres, 
etc., and which may occur at any age, need not detain us. It is 
described in connection with the primary diseases on which it 



432 INFANTILE PARALYSIS. 

depends. But there is a form of paralysis which in the present 
state of our knowledge we must consider an idiopathic disease, and 
which is peculiar to the first years of life, or is so rare at other 
periods that it is proper to regard it as strictly a disease of infancy 
and early childhood. It occurs between the ages of six months 
and three years. 

Symptoms. — The previous health of the patient is usually good. 
The paralysis does not always commence in the same manner. In 
some it begins abruptly, after sound sleep. The child goes to bed 
well, sleeps through the night, and awakens in the morning 
paralyzed. I have known it to occur in one instance after sleep 
in the middle of the day. In these cases there has sometimes been 
an exposure, before the sleep, to wind or rain, or from sitting upon 
a cold stone. In other and the majority of cases the paralysis is 
preceded by a very decided febrile movement, which comes on 
suddenly, without appreciable cause, and after a few days the 
power of motion is found to be lost in one or more of the limbs. 
There is no symptom during the febrile movement to indicate any 
affection of the brain: consciousness is retained, and there is no 
more headache or apparent liability to convulsions than occurs in 
other pathological states accompanied by an equal amount of fever. 
In whatever way the paralysis begins, it is at its maximum in the 
commencement. Occurring as by a stroke, the full extent of the 
paralytic state is exhibited at once, and so far as there is any sub- 
sequent change, it is an improvement, as regards the number of 
muscles affected, and the degree of the paralysis. Most frequently 
the paralysis affects one or both lower extremities. Occasionally 
one of the upper extremities is also paralyzed in addition to the 
lower, but paralysis of an upper extremity is less in degree, and 
disappears sooner, than that of the lower. The bladder and lower 
bowels remain unaffected, since only the muscles of volition are 
involved. Sensation is unimpaired in the affected limbs, and in 
the commencement there is even in some cases a state of hyperes- 
thesia (West). The febrile movement, which precedes and accom- 
panies the paralysis in certain cases, gradually abates, and in a few 
days nothing abnormal remains except the loss of power in the 
affected muscles. These muscles are in a flaccid and relaxed state, 
so that the limb falls by its weight when unsupported, and they are 
usually free from pain. The number of muscles paralyzed varies 
greatly in different cases. Only one muscle or a single group of 
muscles may be affected, or, on the other hand, both the extensor 
and flexor muscles of two or more limbs. In the opinion of Mr. 



PROGNOSIS — PROGRESS. 433 

Adams, the following table exhibits the groups of muscles and 
single muscles most frequently involved, and in the order stated. 

Groups. 

1. Extensors of toes, and flexors of the foot. 

2. Extensors and supinators of the hand. 

3. Extensors of leg, and with them usually the first group. 

Single Muscles. 

1. Extensor longus digitorum of toes. 

2. Tibialis anticus. 

3. Deltoid. 

4. Sterno-mastoid. 

Prognosis — Progress. — The paralysis in nearly all cases soon 
begins to abate. The power of motion returns little by little, and 
whatever improvement occurs is permanent. There is no retro- 
gression in the convalescence. The sooner improvement com- 
mences, the more favorable is the prognosis. In the most favorable 
cases there is complete restoration in from three to four weeks. 
In other patients, while certain of the muscles regain the power 
of motion, other muscles, oftener those of the lower extremity 
than upper, do not recover their function, and, unless proper reme- 
dial measures are employed, and even with them in certain instances, 
atrophy soon commences. The temperature of the paralyzed limb 
falls three, five, or even eight degrees, and the amount of blood 
which circulates in it is diminished so that the pulse of the limb is 
feebler and its vessels smaller than in health. "With the atrophy 
the contractility of the muscular fibres by the electric current 
diminishes, and in unfavorable cases after a time powerful induced 
and even primary currents have no appreciable effect. The nutri- 
tion of a paralyzed limb is always imperfect, and if the paralysis 
occur in a child, its growth is retarded. Therefore in cases of pro- 
tracted or permanent infantile paralysis of one limb a disproportion 
occurs both in diameter and length between it and that on the 
opposite side. If the paralysis continue, the ligaments of the 
paralyzed limb become relaxed and lengthened. West mentions 
a case of paralysis of the deltoid in which the humero-scapular 
ligaments were so extended that the humerus dropped from the 
glenoid cavity, so as to increase the length of the limb three- 
fourths of an inch. In the paralysis of certain muscles of the 
lower extremity, and continuance of the contractile power in 
28 



434- INFANTILE PAKALYSIS. 

others, we have the conditions which give rise to club-feet, and 
accordingly this deformity is the common result of the paralysis 
when it is not cured. 

Etiology. — Opportunity for post-mortem examinations seldom 
occurs, and what the exact pathological state is which causes the 
paralysis has not been fully ascertained. As most of the cases 
occur during the time of first dentition, it was long believed that 
this physiological process was the chief cause, and hence the term 
dental paralysis by which this disease was designated. It is now, 
however, generally admitted that the evolution of the teeth is not 
a direct cause, and can only operate as a cause by increasing the 
susceptibility of the nervous system. The brain and cerebral 
meninges may also be excluded as sustaining any causative rela- 
tion to the paralysis. There is no symptom indicating that they 
are involved. The mind remains clear, and convulsions are no 
more frequent than in any other disease attended by an equal 
degree of febrile reaction. 

Most of the highest authorities as regards diseases of the nervous 
system, attribute infantile paralysis to disease of the spine. If we 
accept this theory, certainly the cause of infantile paralysis must 
in many instances be one of the mildest of the pathological states 
of the nervous centres, since there are so many cases of speedy 
recovery. Spinal congestion is held by Radcliffe and others to be 
this pathological state. Still there are certain differences in the 
symptoms of spinal congestion as it ordinarily occurs, and those 
present in many cases of infantile paralysis. (See St, Thomas's Hosp. 
Rep., 1870, Barwell.) 

Another theory regards infantile paralysis as entirely a peripheral 
disease, resembling in many instances, both as regards origin and 
nature, facial paralysis as it occurs in adults from protracted ex- 
posure to cold. This theory is thus advocated and enunciated by 
Mr. Barwell : " I do not see how at all Ave can escape the conclu- 
sion that this paralysis is purely peripheral ; a malady affecting the 
ultimate fi.br illse of distribution of the nerves among the muscular 
elements." . . . . a Its essence lies probably in some subtile de- 
rangement in relationship between the ultimate muscular and 
terminal nerve-fibres, perhaps from some inflammatory, perhaps 
from some chemical or nutrient charge." (Ibid.) This theory may 
not be broad enough to cover those cases in which the paralysis is 
extensive, as when both lower and upper extremities are involved, 
but the facts observed in certain cases do harmonize better with 
this theory than with that of a central origin, and I would ask 



ANATOMICAL CHARACTERS. 435 

whether in some instances, at least, the supposed hyperesthesia 
which attends certain cases may not he a tenderness due to the 
anatomical change affecting the terminal nerve-fibres alluded to 
by Barwell. The following is an example of the class of cases 
which the symptoms indicate have a peripheral rather than central 
origin. A. K., German, female, aged three years four months, 
fleshy; had been in the habit of sitting on the ground near the 
house and on the door-sill. On July 2d, 1871, she had a sound 
sleep in the afternoon, having been entirely well previously, and 
awoke trembling and with a high fever at 3 J P.M. At 8 P.M., the 
febrile excitement continuing, general clonic convulsions occurred, 
lasting about ten minutes. At this time I was called to see her, 
and found the face flushed, surface hot, and pulse about one hun- 
dred and thirty. Consciousness returned after the convulsion. 
The intelligence was good, tougue moist and slightly furred, 
bowels rather constipated, and the urine was freely passed. The 
febrile excitement continued two days, when it gradually and en- 
tirely abated, but before it ceased paralysis of the left lower ex- 
tremity was observed. Eo weight at first could be sustained 
upon this limb, and it hung powerless when we endeavored to 
make her walk. The attempt caused her to cry, as if in pain, and 
pressing upon the thigh, or moving it, had the same effect. The 
thigh of this limb did appear slightly swollen on inspection, but 
measurement did not indicate any notable enlargement. The dif- 
ference in circumference was certainly not more than one-eighth to 
one-fourth of an inch. There was no appreciable increase of heat 
in the thigh over the general temperature of the body. Sensibility 
remained in every part of the limb, and the loss of power was not 
complete, for on the first day, as soon as the paralysis was ob- 
served, slight and imperfect movements could be produced by pinch- 
ing the limb. In three weeks the use of the limb was fully restored, 
by mildly stimulating liniments, and simple medicines to regulate 
the bowels. It does not seem improbable that in the future, when 
the true pathology of this disease is revealed, we shall find that 
there are two forms of it, one having a centric origin, and the 
other an eccentric, cases like that described above being examples 
of the latter. 

Anatomical Characters. — All muscular fibres which are in a 
state of disuse, begin in a few weeks to atrophy, and undergo 
fatty degeneration. The transverse striae in the primitive muscu- 
lar fasciculus gradually disappear and are replaced by granules of 
fat, and later still by small oil globules. If we examine with the 



436 INFANTILE PARALYSIS. 

microscope the fibres from a muscle which has been a considerable 
time paralyzed, but which has still some electric contractility, we 
will find in places the striae remaining, but numerous opaque 
granules of a fatty nature within the sarcolemma wherever the 
striae are absent, and in other places, where the degeneration is most 
advanced, oil globules occur, always small. If the paralysis is 
more profound, the striae have all disappeared. At a later v stage, 
usually after some years in cases of complete and incurable paraly- 
sis, the fatty matter may be to a considerable extent absorbed, and 
the fibrous network of the muscle which remains presents a ten- 
donous appearance. There is a great difference, however, in differ- 
ent cases, as regards the rapidity with which these changes occur. 
Hammond states that he found the striae remaining in two cases 
after the lapse of more than four years of decided paralysis. The 
nerves of the paralyzed part also undergo atrophy. 

Little can be said that is positive and satisfactory in reference 
to those anatomical changes, whether peripheral or centric, which 
are believed to cause the paralysis. As to the peripheral cause, 
nothing is known beyond conjecture. As to the spinal cause, 
several autopsies have been made of those, dying of various ages, 
who were paralyzed from infancy or childhood, but there has been 
no uniformity as regards the condition of the spinal cord or its 
meninges, and an examination of the records of these cases con- 
vinces me that most of them were examples of spinal disease, 
which may occur at any age, and not of the true infantile paralysis. 
Certain diseases of the spine in the child will give rise to paralysis 
as they do in the adult, but we should not regard a case as one of 
infantile paralysis unless it has the clinical history of that disease. 
Thus, writers have included in their description of the lesions of 
infantile paralysis a case reported by Berend, in which the cele- 
brated Recklinghausen found tubercles in the spine. Another 
case, reported by Hutin, presented atrophy of the lower part of the 
spinal cord, but the paralysis, unlike that which we are describing, 
began at the age of seven years. The following are the chief 
lesions which have been found in reported cases : sclerosis of spinal 
cord (increase of its connective tissue, and more or less atrophy of 
the nervous substance by compression) (Laborde and others), cica- 
trix and clot (Hammond), spinal arachnitis, with thickening of 
meninges (Jaccoud), atrophy of anterior roots of spinal nerves 
(Longet), atrophy of lower part of spinal cord (Hutin), tubercles 
(Berend). Finally, Fleiss, Adams, and Rilliet and Barthez ex- 
amined cases and found no lesions of the spine or spinal meninges. 



DIAGNOSIS — PROGNOSIS. 437 

It is obvious that the discovery of such varied lesions in the spi- 
nal cords of those who have been paralytic from childhood aids but 
little in elucidating the pathology of infantile paralysis. These 
observers have seen the lesions in spinal, whether they have or 
not in cases of true infantile paralysis, but it is to be observed that, 
tubercles excepted, these lesions have been such as would be likely 
to result from intense and continued congestion of the cord. 
Intense congestion may cause apoplexy, and congestion long con- 
tinued often causes a subacute and chronic inflammation, among 
the results of which, in case of the spine, would probably be 
sclerosis and atrophy with thickening and opacity of the meninges. 
Or may not the atrophy be a result of the paralysis just as atrophy 
of the nerves occurs ? But in order to determine the exact relation 
which the state of the spine sustains to infantile paralysis, accu- 
rate and minute examination of the spinal cord is required in those 
who have died of intercurrent diseases at an early period of the 
paralysis. The researches of J. Lockhart Clarke have demonstrated 
that the microscope may aid greatly in elucidating the cause and 
nature of obscure diseases of the nervous system. It has already, 
in his hands, revealed structural changes of the cerebro-spinal axis 
in certain affections, which without its aid would be considered 
neuroses. It cannot be doubted that it will yet contribute much 
to a better understanding of this disease. 

Diagnosis. — This is easy as soon as the attention of the physi- 
cian is directed to the state of the limbs. In a large proportion of 
cases the mother or nurse first observes the paralysis, and calls the 
attention of the physician to it. A knowledge and recollection of 
the facts in relation to infantile paralysis should lead the physician 
to examine the state of the limbs in all cases of great febrile 
excitement in young children, occurring without apparent cause. 

Prognosis. — It may be confidently predicted, if the child is seen 
early, and correctly treated, that the paralysis will diminish, if it 
cannot be entirely cured. If the paralysis has continued a con- 
siderable time, and there is no electric contractility of the muscles, 
there is poor prospect of any improvement. The induced current 
will fail, sometimes, to cause muscular contraction, when the 
direct current may produce it ; but if there is no response to the 
direct current, there is no therapeutic agent which can restore the 
use of the limb. 

In cases seen soon after the paralysis commences, and before the 
stage of atrophy, the prognosis is most favorable, when there is 
still slight voluntary motion, and improvement commences early. 



438 INFANTILE PARALYSIS. 

In most instances, even when the paralysis has been mild, and 
of comparatively short duration, the limb, although its motion is 
fully restored, is for a long time weaker than the limb on the 
opposite side. 

Treatment. — A physician called at the commencement of the 
paralysis should endeavor to remove every cause which might 
increase the irritability of the nervous system. It is proper to 
scarify the gums, if much swollen and tender from dentition, the 
bowels should be kept regular, worms, if present, expelled by 
appropriate medicines, and the diet be plain and unirritating. 
As the cause of the paralysis is in the commencement still opera- 
tive, measures are appropriate which are calculated to remove it. 

Local treatment is very important at all periods of the paralysis. 
In the first days a tepid hip-bath employed daily, with brisk fric- 
tion of the surface, has a salutary effect. Stimulating embrocations 
along the spine, and upon the paralyzed limb, are appropriate also 
at an early date. Possibly, if there is a strong probability of 
spinal congestion, cold applied along the spine, by ether spray or 
otherwise, might be useful, but I am not aware that it has been 
employed in this disease. If the paralysis appear to have a central 
origin, ergot, the bromide and iodide of potassium, which may be 
administered variously combined, or singly, are the appropriate 
remedies for the first twelve or fourteen days. Administered every 
three or four hours in proper dose, they are the most effectual of 
all internal remedies for diminishing spinal congestion, and pre- 
venting effusion, and permanent structural change in the cord. 

If the paralysis continue, or is not progressively diminishing, 
we should not delay more than two weeks from the commencement 
of the disease before employing appropriate measures to restore 
the use of the limbs, and prevent atrophy of the muscles. The 
expectant plan of treatment which is proper in many diseases of 
children is unsuited to this. Muscular atrophy may commence in 
three weeks, and the further it has advanced, the more difficult 
and tedious will be the cure. Therefore, by the close of the second 
week if the paralysis continue, or is not rapidly disappearing, iron 
as a tonic with strychnia should be prescribed. There is probably 
no better formula for the exhibition of these agents than the fol- 
lowing from Prof. Hammond: — 

R. Strycli. sulphat. gr. j ; 
Ferri pyrophosphate ^ss ; 
Acidi phosphorici dilut. §ss; 
Syr. zingih. §iijss. Misce. 



TREATMENT. 439 

One-third of a teaspoonful, or one-ninetieth of a grain of strychnia, 
is sufficient for a child of two years, administered three times 
daily. Hillier, Barwell, and others have employed subcutaneous 
injections of strychnia, with, it is stated, a good result. While in 
the first and second weeks the child has been allowed to remain 
quiet, he should now be encouraged to use his limbs. Frequent 
muscular contraction must, if possible, be produced, and the 
voluntary movements, when not totally lost, aid greatly in pro- 
moting the nutrition of the muscles and restoring their function. 
Immersing the limb for half an hour in water at a temperature 
of 110 or 115 degrees, rubbing the limb with a coarse towel, and 
kneading the muscles, aid also in restoring nutrition and tone to 
them. 

But, fortunately, we have an invaluable agent in the subtle 
electrical fluid, which can be made to penetrate the muscles and 
cause their contraction when every other measure has failed. The 
induced current should be employed upon the limb every day, or 
second day, if it cause the muscles to act, but if the loss of power 
is of long standing, or complete, so that the induced current is not 
sufficiently powerful, the direct current should be used instead. It 
is not regarded as important which way the current passes, pro- 
vided the muscles contract. 

In a large proportion of cases a cure cannot be effected until the 
lapse of several months, so that the patience of the physician and 
friends may be put to the test; but if muscular atrophy can be 
prevented, and the limb kept at near the normal temperature, this 
mode of treatment will ordinarily in the end be successful. The 
primary affection which caused the paralysis will, with some 
exceptions, abate of itself, so that the state of the muscles and their 
nervous supply demand the whole attention. Observations show 
that by treatment perseveringly employed, fatty -degeneration of 
the muscular fibres can not only be arrested, but the fat which has 
already been deposited within the sarcolemma may be absorbed, 
and the muscular striae restored. In those cases in which it has 
been necessary to employ the direct current, the induced should be 
employed, whenever by the improvement of the case it is found 
sufficiently powerful. 



440 FACIAL PAEALYSIS, 



CHAPTER XYI. 

FACIAL PAEALYSIS. 

Causes. — Facial paralysis, in the new-born, commonly occurs 
from pressure of the blade of the forceps upon the portio dura, at 
a point external to the stylo-mastoid foramen. It may also occur in 
children of any age, as it is known to in the adult, from exposure 
of the face to a cold wind. The pressure of a tumor upon some 
part of the portio dura, or even of the fist of the child placed under 
the face during sleep, may cause it. It may also result from disease 
of the temporal bone, producing pressure on the nerve, as caries, 
periostitis, suppuration, or hemorrhage into the aquseductus 
Fallopii, and also from intra-cranial disease affecting the pons 
Varolii or the medulla oblongata. 

Symptoms. — The portio dura, which is a nerve of motion, supplies 
the muscles of the face, and therefore its loss of function is at once 
manifest in distortion of the features. The eye of the affected side 
remains open in consequence of paralysis of the orbicularis palpe- 
brarum, the upper lid being raised by the levator muscle, which is 
not paralyzed, as its nerve is derived from the third pair. From 
the inability to wink, the eye becomes irritated by dust and con- 
stant exposure, and, in children old enough to have an abundant 
lachrymal secretion, the tears are apt to flow over the cheek. On 
account of the paralyzed and relaxed state of the facial muscles 
the mouth is drawn towards the healthy side, while the affected 
side presents a swollen appearance. Movement of the eyebrow 
and of the anterior portion of the scalp on the paralyzed side is 
also impossible, since the occipito-frontalis and corrugator supercilii 
are supplied by the portio dura. If the cause of the disease is 
located above the origin of the chorda tympani, the flow of saliva, 
and consequently the taste, on the affected side are impaired. If the 
injury is posterior to the gangliform enlargement, those symptoms 
are superadded which are due to paralysis of the petrosal nerves. 

Prognosis. — This depends on the cause. If the cause is peri- 
pheral, as from the pressure of the forceps or from cold, the prog- 
nosis is favorable. In cases of deep-seated lesion, unless syphilitic, 



PARALYSIS WITH APPARENT HYPERTROPHY. 441 

the prognosis is usually unfavorable. A syphilitic lesion can often 
be removed by appropriate remedies and the paralysis cured. 

Treatment. — In the paralysis of the new-born, from pressure of 
the forceps, all that is required is occasional rubbing or gentle 
kneading over the affected muscles. In those who are older, the 
nature of the cause, so far as ascertained, must determine the 
treatment. If there are glandular swellings, and discharge from 
the ear from scrofula, cod-liver oil and the syrup of the iodide of 
iron are required internally, with appropriate external treatment 
of the glands and ear. If syphilis is the cause, mercurials and 
the iodide of potassium should be employed. If the patient does 
not begin soon to improve, the treatment recommended for infan- 
tile paralysis, modified somewhat on account of the difference in 
location, is appropriate. Iron and strychnia may be administered 
internally; friction, kneading, hot applications, and the electric 
current employed. The current should have only moderate inten- 
sity, for a high degree of it might injure the vision. It should be 
applied every second day, with one pole over the mastoid foramen, 
and the other moved slowly over the muscles. 

PAKALYSIS WITH APPARENT HYPERTROPHY. 

This is a rare disease. It was first described by Duchenne in 
1861, and since the attention of the profession was directed to it, 
cases have been observed on the continent, in Great Britain, and 
this country. Though our acquaintance with this disease is so 
recent, it has been fully and accurately described by various writers 
in our language. The Transactions of the Lond. Path. Soc. for 1868 
contain a translated paper relating to this disease, communicated by 
M. Duchenne, with photographic views, remarks by Lockhart Clarke, 
and also the histories of two cases occurring in London, and ex- 
hibited to the society by Adams and Hillier. In this country an 
elaborate paper has appeared on this form of paralysis, from the pen 
of Dr. Webber, of Boston, who succeeded in collecting the records 
of forty-one cases. (Bost. Med. and Surg. Journ., Nov. 17, 1870.) 
Meigs, and Pepper, and Prof. Hammond have described this dis- 
ease in their treatises, and the following wood-cut represents a case 
which occurred in the practice of the last gentleman, and which 
conveys a good idea of the appearance of one affected with this 
paralysis. In certain cases, however, as in one figured by Duchenne, 
there are still greater curvatures and enlargement than are repre- 
sented in this wood-cut. 



442 



PAEALYSIS WITH APPARENT HYPERTROPHY. 



Symptoms. — This disease in a considerable proportion of cases 
begins in infancy, and attention is first directed to itswhen the 
patient attains the age at which it begins to stand and walk, which 
is not ordinarily till some months later than the usual time. In 
eleven of the cases tabulated by Webber in which the disease had 
an early commencement, walking was impossible till between the ages 
of seventeen months and three years, and then it was in a clumsy 
manner. The gait, which is unsteady and waddling, has been 
compared to that of a duck. The child stands with the legs wide 
apart, and, from the unsteadiness of the gait, frequently stumbles 
and falls. It is admitted by those who have had the best oppor- 
tunities to study the disease, that the muscular weakness com- 
mences before there is any appreciable enlargement. Therefore, if 
the disease begin after the child has walked, 
the peculiar clumsy gait attracts attention 
before there is anything in the appearance 
to indicate the nature of the disease. 

The enlargement ordinarily occurs first in 
the calf of one leg, then in the opposite calf, 
and later in the thighs and hips. In Nie- 
meyer's case, the muscles of the gluteal re- 
gion were first affected. When the disease 
is fully developed, the spine is so incurvated 
that a perpendicular line from the most poste- 
rior of the spinous processes falls behind the 
sacrum. Duchenne attributes the curvatures 
to weakness of the erector muscles of the 
spine. 

As the disease advances, the muscles of 
the trunk and upper extremities become in- 
volved, though the enlargement is less rapid 
and less in degree in these muscles than in 
those of the lower extremities. Finally, in 
advanced and severe cases walking is impos- 
sible, and the patient is obliged to remain in 
a reclining posture. Movements are now 
often painful, and distortions may occur on 
account of the loss of antagonism in the 
muscles. Experiments show that in some 
cases the electric contractility of the muscles remains nearly 
normal, while in other cases it is impaired. The skin retains its 
normal sensibility. The intellectual faculties are usually more or 




ANATOMICAL CHARACTERS. 443 

less impaired, especially in those cases which begin in early infancy. 
This disease is chronic, rarely terminating till after five or six 
years, and in many not till a considerably longer time. 

Anatomical Characters. — There have been so few post-mortem 
examinations of those who died having this disease, that it is 
still uncertain whether there is any centric lesion. Cohnheim 
examined the spinal cord in one case, and could find nothing ab- 
normal. Recently, Mr. Kesteven has examined the brain and 
spinal cord from a case, and found dilatation of the perivascular 
canals, both in the brain and spinal cord, and also spots of 
granular degeneration chiefly in the white substance, "caused by 
loss of cerebral tissue replaced by morbid matter." (Journ. of 
Mental Sci., Jan. 1871). As this child was imbecile, it is not 
improbable that these lesions were connected with the mental 
state, and not the muscular disease. It is probable, from the facts 
which have been observed, that the lesions of this paralysis are 
eccentric, or if central lesions occur, that they are consecutive and 
subordinate. As the disease consists in a sclerosis, or hyperplasia of 
the connective tissue surrounding the muscles, there is sufficient 
explanation of the paralysis in the impairment of function, and 
atrophy of muscular fibres, which such a hyperplasia would be likely 
to produce by its mechanical effect. Analogous examples will occur 
to the reader, of impairment or loss of function of internal organs, 
from hyperplasia of their connective tissue. Still, in those cases of 
this disease which have been observed from their commencement, 
weakness of the muscles has appeared before there was that 
degree of hyperplasia which produced any decided enlargement 
of the affected part. 

The disuse of the muscles increases their atrophy, consequently 
in cases of this disease which have continued a considerable time, 
and are fully developed, the microscope shows not only atrophy of 
those muscles whose connective tissue have undergone hyperplasia, 
but also to a certain extent of those which are adjacent, and have 
a similar function, but are not the seat of the disease. The affected 
muscles present a pale yellowish hue, resembling, says Xiemeyer, 
the appearance of lipoma. Examining by the microscope, we find 
in addition to a large increase in the fibrous tissue, and atrophy 
and in some places disappearance of the muscular element, more or 
less fatty matter, granular and globular, occupying the interstices. 
Mr. Kesteven describes as follows the appearance of the muscles in 
the case which he examined: "The muscular substance is pale, 
almost white, and very greasy. The superabundance of fat is 



444 PAKALYSIS WITH APPARENT HYPERTROPHY. 

evident to the naked eye. The muscular fibres present the ordi- 
nary striation, but less distinctly than usual. The ultimate fibres 
are pale, and separated by a large increase of areolar and fibrous 
tissue. 

Causes. — These are obscure. Duchenne, in cases which he ex- 
amined, could find no evidence of inherited taint or predisposition. 
Nevertheless, in several of the recorded cases one or more brothers 
or sisters were similarly affected, showing some latent cause in the 
family. In one case observed by Duchenne the disease appeared 
to be congenital, for at birth the limbs were unusually large, and 
the patient when he came under observation had never been able 
to walk. ~No relation has been observed between syphilis, scrofula, 
or other diathetic diseases, and this form of paralysis. Boys are 
more apt to be affected than girls. Of the cases embraced in the 
statistics of Dr. "Webber, thirty-eight were boys and seven girls. 

Prognosis. — This disease is in most instances progressive, termi- 
nating fatally after a variable period. It is in its nature chronic, 
rarely ending in less than S.ve or six years, and a considerable 
proportion living longer, some even attaining adult age. The 
paralysis may be stationary for a time, but afterwards continue to 
increase. Duchenne has reported one case of recovery. In two or 
three other instances patients appeared to improve somewhat under 
treatment, but the writers admit they may have become worse 
afterwards. Death is apt to occur, not directly from the paralysis, 
but from some intercurrent disease, especially of the lungs. 

Treatment. — The treatment thus far employed has been chiefly 
local, consisting in the use of electricity, and kneading or sham- 
pooing over the affected muscles. Both the primary and induced 
electrical currents have been employed, but, unfortunately, with- 
out any appreciable benefit in most cases. Benedikt, who claims a 
better result from electrization than any other observer, applied 
the copper pole over the lower cervical ganglion and the zinc pole 
along the side of the lumbar vertebrae by means of a broad 
metallic plate. 



SECTION II. 

DISEASES OF THE RESPIRATORY SYSTEM. 



CHAPTER I. 

CORYZA. 



The term coryza is applied to inflammation of the Schneiclerian 
membrane. It is acute or chronic. The acute form is primary or 
secondary. Acute primary coryza is common in infancy and child- 
hood. Its usual cause is exposure to currents of air, to cold, and 
especially to sudden changes of temperature from warm to cold. 
The cause is the same as that in the ordinary forms of bronchitis. 
These two diseases frequently indeed coexist, occurring from the 
same exposure. The inflammation in such cases commences upon 
the Schneiderian membrane, immediately upon the operation of 
the cause, and soon after extends to the bronchial tubes. Acute 
coryza may also be produced by the inhalation of irritating vapors, 
hot air, or dust, and also by the presence of a foreign body, as a 
button or bean, in the nostril. 

Secondary coryza is commonly due to a specific cause. The 
diseases in connection with which it occurs are hooping-cough, 
measles, scarlet fever, diphtheria, and constitutional syphilis. In 
the infant, coryza is one of the first manifestations of hereditary 
syphilitic taint. 

Acute primary coryza ordinarily abates in from one to two 
weeks. The secondary form gradually declines, in most cases, 
when the primary affection on which it depends is cured. Syphi- 
litic coryza is more protracted than the primary form, or than that 
accompanying the eruptive fevers. Some children are so liable to 
coryza that it occurs whenever they take cold. Occasionally it is 
so frequently renewed in the winter months, that it resembles the 
chronic form of the disease. 

Chronic coryza is commonly dependent on a dyscrasia. It cor- 



446 CORYZA. 

responds with chronic inflammation of the external ear, and otor- 
rhea is not infrequent in connection with it. The dyscrasia is 
indicated "by pallor, flabhiness of the flesh, and liability to glandu- 
lar swellings. Chronic coryza may also occur in those who have 
good general health, as the result of an acute attack. Many a 
case dates back to one of the exanthematic fevers, the local 
affection continuing after the general health is restored. Rarely 
chronic coryza comes on gradually and without appreciable cause. 

Anatomical Characters. — The alterations which the nasal 
mucous membrane undergoes when inflamed, vary considerably in 
different cases. In the simplest and most common form of coryza, 
this membrane is sometimes in patches, sometimes generally red- 
dened, thickened, and softened. Its papillae are prominent, produc- 
ing an inequality of the surface. Ulcerations are not common in 
simple acute coryza, but they sometimes occur in the chronic form. 

In diphtheria, and not infrequently in scarlet fever and variola, 
the coryza is pseudo-membranous, and when it presents this form 
it is associated with pseudo-membranous angina or laryngitis. A 
case of pseudo-membranous coryza occurring in measles is related 
by M. Guibert. The patient was a rachitic boy, three and a half 
years old. The pseudo-membrane, in severe cases, may cover 
almost the entire surface of the nostrils, but ordinarily it occurs in 
patches. 

Symptoms. — The constitutional symptoms are mild or severe, 
according to the gravity of the inflammation. If the coryza is 
acute and pretty general, there is febrile movement, with thirst 
and loss of appetite. Frontal headache is common, from the 
proximity of the inflammation to the head, or its extension to the 
frontal sinuses. Sneezing is the first symptom in many cases of 
acute coryza. As the inflamed membrane swells, more or less ob- 
struction occurs to respiration. The breathing is noisy, especially 
during sleep, and, in severe cases, the patient is compelled to 
breathe mostly through the mouth. If there is much obstruction 
to respiration, the suffering of the patient is considerable, from the 
sensation of fulness in the nostrils, the headache, and the muscular 
effort required in each respiratory act. 

In- the commencement of coryza the patient experiences a sensa- 
tion of dryness in the nostrils, which is soon succeeded by a thin dis- 
charge of a serous appearance. In the course of a few hours the 
secretion becomes thicker. It is muco-purulent, and remains such 
till the disease begins to decline. Inspissated mucus and crusts 



PROGNOSIS — TREATMENT. 447 

are apt to collect within the nostrils and around their orifice in 
chronic coryza, and sometimes also in the acute disease, if the dis- 
charge is not abundant. These crusts increase the difficulty of 
breathing. Often the acridity of the discharge is such that the 
skin of the upper lip, and around the nostrils, is excoriated. 

Prognosis. — Simple, uncomplicated coryza rarely terminates fa- 
tally. It is only dangerous in young nursing infants, in whom it 
may seriously interfere with lactation. Coryza, accompanying the 
eruptive fevers, although it may increase the suffering, does not 
materially increase the danger. Syphilitic coryza subsides when 
the system is sufficiently affected by anti-syphilitic remedies. 
Chronic coryza is sometimes very obstinate. It may continue for 
months or years, giving rise to'a constant, but often not abundant, 
discharge. 

Treatment. — Common mild attacks of coryza require little 
treatment. The bowels should be kept open, the feet soaked in 
mustard-water, and the body should be warmly clothed. Some 
benefit may be derived from friction with camphorated oil over 
the nose. If coryza commence with symptoms which indicate a 
pretty severe attack, and there are evidences of extension of the 
disease towards the bronchial tubes, an emetic of syrup of ipeca- 
cuanha, given at an early period, moderates the severity of the 
inflammation and may prevent the occurrence of bronchitis. 
Afterwards a simple diaphoretic mixture, as the following, should 
be given : — 

R. Syrnpi ipecacuanhse ^ij ; 
Spirit, aether, nitr. 5j ; 
Syrupi simplicis ^ij. Misce. 

One teaspoonful every three hours to a child of six months. In 
place of sweet spirits of nitre, acetate of potash may be employed 
in the dose of one to two grains for infants ; and if there is decided 
febrile reaction, from half a minim to two minims, according to 
the age, of tincture of digitalis, should be added to each dose. 

In pseudo-membranous coryza the main treatment must be di- 
rected to the accompanying laryngitis, if, as is usual, the latter 
affection is present, since the coryza is much less dangerous than 
the other inflammation. Still, if it cause any obstruction to the 
respiration and increase the suffering of the patient, it requires 
attention. The frequent injection into the nostrils of a solution of 
chlorate of potash in water, with Rve or six drops of carbolic acid 
to each ounce, exerts a beneficial effect upon the inflammation, and 
aids in removing the accumulation of fibrin, mucus, and pus. It 



448 CORYZA. 

should be employed several times in the course of the day. Alum 
injections, four or five grains to the ounce of water, are also useful 
in a certain proportion of cases ; or a solution of one of the mineral 
astringents may be employed, as liquor ferri subsulphatis, acetate 
of lead, sulphate of copper, or nitrate of silver. The bromine solu- 
tion described in our remarks on the treatment of croup will also 
be found useful, injected into the nostrils. 

In most cases of pseudo-membranous coryza constitutional mea- 
sures are required, on account of the disease with which it is 
associated. In cases of acute simple coryza, and in the pseudo- 
membranous, inhalation, through the nostrils, of the vapor of hot 
water or of steam from hops often gives relief ; occasionally it is 
an important part of the treatment. Syphilitic coryza requires 
those measures which are appropriate for constitutional syphilis. 

Chronic coryza, dependent on a dyscrasia, is best treated by 
tonic and alterative remedies. The various ferruginous prepara- 
tions, as wine of iron, tincture of the chloride of iron, iron lozenges, 
may be advantageously employed, or the vegetable tonics. If 
there are pallor, softness of flesh, and especially glandular swellings, 
indicating a scrofulous state of system, the syrup of the iodide of 
iron is useful, with or without cod-liver oil. The diet should be 
nutritious, and the hygienic measures such as invigorate the gene- 
ral health. Injections into the nostrils of a solution of alum, five 
grains to the ounce, of nitrate of silver, three to five grains to the 
ounce, or of one of the other mineral astringents, are sometimes 
useful in connection with constitutional measures. An excellent 
formula in chronic coryza, for application to parts which can be 
reached by a camel's-hair pencil, is the following : — 

$. Ung. hydrarg. ammoniat., 
Axungise, equal parts. Misce. 

At the Out-door Department of Bellevue, this ointment, or the 
citrine diluted, in the same proportion, has proved more effectual 
in this disease than any other local remedy. It should be applied 
three times daily, as far within the nostrils as possible. 

Dr. J. F. Meigs, of Philadelphia, recommends the following 
ointment in chronic coryza, to be applied at night, after the use of 
injections through the day: — 

I£. Unguenti hydrargyri nitratis 5$s ; 
Extracti belladonnas gr. x ; 
Axungire §ss. Misce. 

"It should be applied," says Dr. Meigs, "after being completely 



SIMPLE LARYNGITIS. 449 

softened by a gentle heat, on a camel's-hair pencil, care being taken 
to apply it thoroughly to the surface of the mucous membrane 
itself, and not merely to the outside of the hardened scabs." 



CHAPTER II. 
SIMPLE LARYNGITIS. 

Simple acute laryngitis occurs at all ages, but it is so common 
in infancy and childhood that it is proper to treat of it in a work 
relating to the diseases of these periods. Like other inflammatory 
affections of the air-passage, it is most common in the cold months 
or when the weather is changeable. Its usual cause is, therefore, 
exposure to cold. Crying, protracted and violent, and the inhalation 
of acrid vapors, are occasionally causes. Simple or erythematous 
laryngitis also occurs in connection with certain other diseases, 
among which may be mentioned measles, scarlatina, and variola. 
In most cases of bronchitis, also, and in many of pneumonia, there 
is laryngitis, though its symptoms are, in great measure, obscured 
by those of the graver affection. More or less laryngitis is com- 
mon in pharyngitis, due to extension of the inflammation. 

Symptoms. — Ordinarily, in cases of simple or erythematous laryn- 
gitis, produced by the impression of cold, coryza precedes and ac- 
companies the attack. The first symptom is chilliness, followed 
by sneezing, and a discharge from the nostrils due to the coryza. 
The commencement of laryngitis is indicated by hoarseness, which 
is ^apparent when the child cries, or, if old enough, when he 
attempts to speak. There is, in severe cases, often complete loss 
of voice, so that the child cannot speak above a whisper. I have 
noticed this most frequently in the laryngitis which accompanies 
measles. Cough is also a common symptom of this disease. It is 
at first dry and husky, becoming loose in the course of a few days. 
But expectoration is scanty, except when the inflammation has 
extended to the trachea and bronchial tubes. 

This disease is often accompanied by soreness of the throat, no- 
ticed in the act of coughing or when the larynx is pressed with the 
finger. In simple laryngitis, when uncomplicated, the respiration 
remains nearly natural and. the pulse is but little accelerated. In 
mild cases the nature of the disease is often not apparent as long 



450 SIMPLE LARYNGITIS. - 

as the child remains quiet, in consequence of the absence of symp- 
toms, but the character of the voice, when he cries or speaks, or of 
the cough, reveals at once the nature of the affection. 

Simple acute laryngitis subsides in from one to two weeks. Oc- 
casionally it lasts three or four weeks before the symptoms entirely 
disappear. Death, which is rare, is due to some complication. 

Chronic laryngitis is much less frequent than the acute form. 
Its anatomical characters are similar to those in other chronic 
inflammations affecting mucous surfaces, namely, thickening and 
more or less infiltration of the mucous membrane, increased pro- 
liferation and exfoliation of the epithelial cells, and increased 
functional activity of the muciparous follicles. 

In the adult chronic laryngitis is common as one of the lesions 
of the syphilitic or tubercular disease. In the child this disease is 
more rare, but it sometimes occurs in connection with pulmonary 
or bronchial tubercles. Such patients are emaciated, and have the 
ordinary symptoms of tuberculosis. Chronic laryngitis also occurs 
in young children, usually infants, as one of the manifestations of 
the strumous diathesis. I have records of about twelve such cases, 
mostly nursing infants. Some of these patients had mild bronchitis, 
but it was obviously subordinate to the laryngitis. Their respira- 
tion was noisy and harsh, continuing of this character for several 
weeks and even months. The cough was also harsh and loud, 
conveying the idea of thickening and relaxation of the mucous 
membrane covering the vocal cords. Their respiration was not 
notably accelerated, and the blood was apparently fully oxygenated, 
though the friends were often alarmed by the noisy breathing and 
cough. 

In this form of chronic laryngitis there is little expectoration, 
the fever is slight or absent, the appetite remains unimpaired, jjnd 
the general condition of the child is good. There are from time 
to time exacerbations, and occasionally improvement is such as to 
encourage the hope of speedy cure, but in the cases which I have 
seen there has not been complete intermission in the disease till 
the final recovery. Those patients whom I have been able to 
follow through the disease have recovered in from three or four 
months to one year. 

This chronic laryngitis is to be distinguished from frequent 
attacks of acute laryngitis, which are due to fresh exposures, and 
are accompanied by the ordinary symptoms of the acute disease. 
It is to be distinguished from protracted acute laryngitis, which 
sometimes does not entirely subside in less than a month or six 



TEEATMENT. 451 

weeks, by its longer duration, the greater thickening of the in- 
named membrane, and more noisy respiration. Certain cases of 
chronic laryngitis result from the acute disease, the inflammation 
being perpetuated by the struma or dyscrasia of the patients. 

Anatomical Characters. — In simple acute laryngitis the mucous 
membrane of the larynx presents the usual appearance of mucous 
surfaces when inflamed, namely, redness and thickening. It is also 
somewhat softened. Ulcerations rarely, perhaps never, occur in 
primary acute laryngitis. When present in chronic laryngitis, the 
ulcers are small and situated upon or near the vocal cords. Tu- 
bercular and syphilitic ulcers of the larynx are much more rare in 
children than adults. The inflammation in simple acute laryngitis 
usually extends over the whole surface of the larynx, and also to 
the upper part of the trachea. It may be pretty uniform, or more 
intense in one place than another, and, like other mucous inflam- 
mations, it is accompanied by more or less rapid proliferation, and 
exfoliation of epithelial cells. In most cases of simple laryngitis, 
whether acute or chronic, the inflammation extends to the pharynx, 
producing redness and thickening, though generally moderate, of 
the mucous membrane which covers it. Examination of the fauces 
therefore aids in diagnosis. 

In the adult oedema glottidis occasionally results from laryn- 
gitis. In the child there is little danger that this will occur, in 
consequence of the anatomical character of the larynx. In early life 
there is but little submucous connective tissue in the larynx, and 
therefore less submucous infiltration or effusion during the inflam- 
mation. The structural changes occurring in simple laryngitis of 
infancy and childhood relate almost exclusively to the mucous 
membrane. 

Treatment. — Simple primary and uncomplicated laryngitis re>- 
quires little treatment. Most cases would do well by the employ- 
ment of suitable hygienic measures, without medicines. Benefit 
is, however, derived from the use of demulcent drinks and an 
occasional laxative. A mixture of paregoric and syrup of ipecacu- 
anha, or a small Dover's powder, will relieve the cough if it is 
troublesome. If there is restlessness, a warm mustard foot-bath is 
useful. An important part of the treatment is the application of 
some mild counter-irritant over the larynx. In most instances 
camphorated oil, preceded perhaps by mustard, produces sufficient 
irritation. It should be rubbed several times daily over the throat, 
or a strip of flannel soaked with it may be applied around the 
neck. Chronic laryngitis dependent on syphilis or tuberculosis 



•i52 SPASMODIC LARYNGITIS. 

requires the constitutional treatment which is appropriate for that 
disease. Local measures have but little effect upon this form of 
inflammation . The chronic laryngitis which I have described as 
occurring chiefly in infancy, and which appears to be of a strumous 
character, is apt to be obstinate. The patient should be warmly 
clothed, and constant care should be taken that there be no 
exposure which would endanger taking cold, as this would inevi- 
tably produce an exacerbation of the disease, and counteract all 
that had been gained by remedial measures. This form of chronic 
laryngitis is most satisfactorily treated by the application of 
tincture of iodine upon the neck, directly over the larynx, and the 
internal use of cod-liver oil and the syrup of the iodide of iron. 
Little benefit results in this form of laryngitis from the usual ex- 
pectorant remedies, as squills or senega. 

Spasmodic Laryngitis. 

This is a common disease. It is also called false croup, in con- 
tradistinction to true or pseudo-membranous croup, and, by some 
of the continental writers, stridulous angina or stridulous laryn- 
gitis. It should not be confounded with spasm of the glottis, 
which is a form of internal convulsions, and is not inflammatory. 
It occurs ordinarily between the ages of two and five years. It is 
commonly a sporadic affection, but Rilliet and Barthez state that 
"it is incontestable that it may prevail epidemically." They 
express this opinion, not from their own observations, but chiefly 
from those of Jurine, made in the commencement of the present 
century. 

Causes. — Children in some families are more liable to false 
croup than in others, so that an hereditary tendency to it must be 
admitted. The exciting cause in most cases is exposure to cold. 
False croup is not uncommon in the commencement of measles. 
Narrowness of the rima glottidis, and an excitable state of the 
nervous system, both of which are common in early childhood, 
are predisposing causes. 

Symptoms. — Spasmodic laryngitis is ordinarily preceded for a 
day or two by a slight cough and fever, by symptoms of mild 
coryza or catarrh, such as all children are liable to on taking cold. 
In exceptional cases these symptoms are absent, and the disease 
begins abruptly. Singularly, it commences nearly always at 
night, after the first sleep, between ten and twelve o'clock. The 
sleep is usually quiet and natural, but the child awakens with a 



SYMPTOMS. 453 

loud, barking cough. There is great dyspnoea, and the respiration 
is harsh or whistling, on account of the narrowing of the chink of 
the glottis from the swelling and tension of the vocal cords. The 
face is flushed and indicative of suffering. The child cries, moves 
from one position to another, wishes to be held or carried, seeking 
in vain for relief. The skin is hot, pulse accelerated, the voice 
hoarse or even whispering. After a variable period, usually from 
half an hour to two or three — not more than half an hour with 
proper treatment — these symptoms abate. The patient is then 
somewhat exhausted, and falls asleep. The face is less flushed 
or even pallid, the heat abates, and the pulse is less accelerated. 
The cough, though less frequent, remains for a time barking or 
sonorous, and the respiration, though greatly relieved, is not at 
once entirely natural, but it gradually becomes so. Often there is 
no return of the spasmodic respiration and cough, but sometimes 
the attack is repeated once or more, especially during the subse- 
quent nights. The symptoms vary greatly in intensity in different 
patients. 

As the attack declines, the disease, losing its spasmodic character, 
becomes a simple inflammation. In some there is immediate return 
to perfect health, but often er the inflammation extends not only 
into the trachea, but also into the larger bronchial tubes, and the 
disease is then a laryngo-bronchitis, which gradually subsides. 

The termination is not always so favorable. Spasmodic laryn- 
gitis is, in exceptional instances, the precursor of other serious 
affections, which may prove fatal. It has been stated that measles 
often begins with spasmodic laryngitis. Bronchitis becoming 
capillary, may occur in connection with it, as may also pneumonia, 
and by either of ^hese severe inflammations the prognosis may be 
rendered doubtful. There are a few cases on record in which it 
is believed that spasmodic laryngitis was of itself fatal. In some 
of these cases the dyspnoea was extreme and persistent, and was 
the cause of death. In a case reported by Rogery, on the other 
hand, the respiration became easy before death, and the pulse more 
and more frequent and feeble. Death apparently occurred from 
exhaustion. It is not improbable that, had careful post-mortem 
examinations been made, in those cases of spasmodic laryngitis 
which have ended fatally, other lesions would have been discovered 
besides those located in the larynx, perhaps tracheo-bronchitis, 
with an accumulation of mucus in the larynx, producing suffoca- 
tion, or perhaps sometimes congestion of the brain or lungs and 
serous effusion. 



454: SPASMODIC LARYNGITIS. 

Anatomical Character; Pathology. — The opportunity does not 
often occur of determining the anatomical characters of spasmodic 
laryngitis. I have witnessed but one post-mortem examination. 
A little girl, nine years old, was taken on Friday night with cough 
and dyspnoea, indicating a pretty severe attack. The mother, 
acting through the advice of a friend, gave kerosene oil to her in 
considerable quantity. This was succeeded by obstinate vomiting 
and purging, which continued during Saturday and Sunday. 
Death occurred on Monday. At the autopsy we found uniform 
and intense injection throughout the whole extent of the larynx 
and trachea, and extending into the bronchial tubes. There was 
no pseudo-membrane on the inflamed surface, and but little mucus 
and pus. The solitary follicles of the intestines and Peyer's 
patches were tumefied. There was injection, in places, of the 
gastro-intestinal mucous membrane. The cause of death was 
obviously the diarrhoea, apparently of an inflammatory character, 
and probably produced by the kerosene oil. The condition of the 
mucous membrane of the larynx was that which is ordinarily 
present in spasmodic laryngitis, though in some cases in which 
post-mortem examinations have been made the evidences of laryn- 
geal inflammation were slight. Guersant relates a case in which 
the surface of the larynx seemed to be nearly in its normal state. 
Death in cases of slight laryngitis is due to causes which are 
independent of the larynx. In G-uersant's case there was tuber- 
culosis. 

There is, as has already been intimated, another and an impor- 
tant element besides the inflammation, in the pathology of spas- 
modic laryngitis — an element producing those phenomena which 
render it a disease distinct from simple laryngitis. I refer to spasm 
of the laryngeal muscles. This element pertains to the nervous 
system, so that spasmodic laryngitis is allied both to the neuroses 
and to the inflammations. 

Diagnosis. — The disease for which spasmodic laryngitis is most 
frequently mistaken is pseudo-membranous croup. The friends, 
indeed, usually make this mistake in forming their opinion of the 
case before the physician arrives ; and there can be no doubt that 
many of the cases which physicians have published in medical 
journals as true croup were examples of this affection. The points 
of differential diagnosis are the following : True croup begins 
with symptoms which at first are slight, so as scarcely to arrest 
attention, but which gradually increase in intensity. The cough 
becomes more harsh, and the respiration more difficult, by degrees. 



PROGNOSIS — TREATMENT. 455 

This increase in the gravity of the symptoms occurs by clay as 
well as by night. On the other hand, false croup, though preceded 
by symptoms of coryza, or catarrh, begins abruptly. The symp- 
toms have from the first their maximum intensity, and the time 
at which it commences is the night. Again, the cough in spas- 
modic laryngitis possesses a loud, sonorous character ; while in true 
croup it is harsh or rough, from the presence of the membrane, 
and having, therefore, less fulness. The voice in spasmodic laryn- 
gitis may be hoarse, but it is not lost, or is lost only for a short 
time. It afterwards becomes natural, or is slightly hoarse. On 
the other hand, in true croup, the voice, from being natural at 
first, is gradually extinguished. In fatal cases it soon becomes 
whispering, and continues such till the close of life ; in those that 
recover, the voice remains hoarse for several days. These differ- 
ences are important, and, if fully appreciated, are in most instances 
sufficient to establish the diagnosis. Besides, in a large proportion 
of cases of true croup, portions of the pseudo-membrane may be 
discovered on inspecting the fauces, and the faucial surface is 
deeply injected, while in spasmodic laryngitis there is, with rare 
exceptions, no false membrane upon the surface of the fauces, and 
but a moderate amount of congestion. 

Laryngismus stridulus, or internal convulsions, must not be 
confounded with this disease. It is not inflammatory, but purely 
spasmodic, suddenly commencing and abating — identical, it is 
believed, in character, with tonic convulsions of the external mus- 
cles, but affecting the internal muscles of respiration. This disease 
has already been fully described. 

Prognosis. — Little need be added, as regards the prognosis, to 
what has already been stated. While a favorable opinion in 
reference to the result may ordinarily be expressed, the physician 
should not forget the fact that death may occur. Symptoms indi- 
cating an unfavorable termination are: great and continued dysp- 
noea, not diminished by the proper remedial measures ; stridulous 
expiration as well as inspiration ; lividity of the prolabia and fin- 
gers ; pallor and coldness of surface ; pulse progressively more 
frequent and feeble. Convulsions and coma may also occur near 
the close of life. 

Treatment. — The indications of treatment are twofold : first, to 
relieve the spasmodic action of the laryngeal muscles ; secondly, to 
cure the laryngitis. To meet the first indication, a warm bath of 
the temperature of about 100° should be employed as soon as possi- 
ble after the commencement of the attack. The patient should be 



456 SPASMODIC LARYNGITIS. 

kept in it ten or fifteen minutes, in order to obtain its full relaxing 
effect. In mild cases a warm foot-bath may be sufficient. A 
second means is the use of an emetic, which should be simultaneous 
with the bath. To children under the age of three years, syrup of 
ipecacuanha should be given, in doses of one teaspoonful, repeated 
in twenty minutes, till vomiting occurs ; or alum and syrup of 
ipecacuanha, two drachms of the former to one ounce of the latter, 
may be given in the same dose.' The alum and the syrup produce 
more prompt emesis than the syrup alone. Children over the age 
of three years, unless of feeble constitutions, are best treated by 
the compound syrup of squills in teaspoonful doses, or a mixture of 
this with syrup of ipecacuanha. It is not often necessary to give 
more than three or four doses, and sometimes one or two are suffi- 
cient to produce vomiting. 

In most cases, by the use of the warm bath and the emetic, the 
symptoms are rendered milder, and convalescence soon commences. 

In the American Journal of the Medical Sciences, April, 1867, Dr. 
R,. R,. Livingston reports a case of laryngitis treated by Squibb 's 
ether. It is stated that portions of pseudo-membrane, from one- 
eighth to three-fourths of an inch in length, were expectorated; 
but the symptoms certainly indicated a spasmodic element as 
decided as in spasmodic croup, and the benefit from the ether was 
apparently due to the relaxation of the laryngeal muscles which 
it produced. The treatment of the patient, who was two years 
old, was commenced by the administration by the mouth of half 
a teaspoonful of the ether, and followed by its inhalation. "In 
precisely eight minutes from the time the patient commenced the 
inhalation, the abnormal muscular exertion ceased ; a general 
relaxation took place; the pulse (which had numbered 150) fell 
to 100." Ether, judiciously employed, will probably prove to be 
a useful remedial agent in spasmodic forms of laryngitis, whether 
or not it has any effect on pseudo-membranous formations. The 
same may be said of chloroform. A large majority of cases, 
however, recover speedily without its employment, by the other 
measures recommended. 

To fulfil the second indication, namely, the cure of the inflam- 
mation, as well as to control the spasm of the laryngeal muscles, 
bloodletting has sometimes been resorted to. It is, however, so 
seldom required, that it may be almost discarded as a part of the 
treatment. In those of full habit, with strong pulse, if the mea- 
sures already recommended should not give relief, one or two 
leeches might be advantageously applied to the top of the ster- 



TREATMENT. 457 

num : but, except in such cases, local bloodletting, and much less 
general, should not be resorted to. 

Attention should always be given to the state of the bowels in 
spasmodic laryngitis. If they are not well open, a purgative 
should be administered. For those that are robust, and with 
considerable febrile movement, the saline cathartics are ordinarily 
preferable, as Rochelle salts, or a purgative dose of calomel may 
be administered. The cathartic should not be prescribed till the 
nausea from the emetic has subsided. By its derivative effect, it 
tends to diminish the laryngitis, and, in severe cases, it may ob- 
viate the need of depletion by leeches. 

Inhalation of the vapor of hot water, and the application of a 
sinapism over the neck and upper part of the sternum, followed by 
an emollient poultice, are useful adjuvants to the treatment. 

When the spasmodic element in the disease is relieved, the case 
becomes one of simple laryngitis, and the general plan of treat- 
ment recommended for that disease is proper for this. Small 
doses of ipecacuanha, or of one of the antimonial preparations, as 
the compound syrup of squills, not sufficient to cause nausea, 
should now be given at regular intervals. I have sometimes 
added to the expectorant one drop of tincture of veratrum viricle, 
for robust children over the age of three or four years, having a 
full and rapid pulse, flushed face, and other evidences of active 
febrile movement. Its effect should be watched, and it should be 
discontinued when its sedative influence on the circulation begins 
to be apparent. It should not be^ given in the spasmodic laryngitis 
which occurs in the commencement of measles. 

If, however, there is not a speedy termination of the disease by 
recovery, or, more rarely, by death, there is nearly always tracheo- 
bronchitis, or a more serious affection, coexisting with the laryn- 
gitis, or following it; therefore, depressing measures should not 
be long continued. Expectorants of a stimulating character, as 
carbonate of ammonia, or syrup of senega, are required in the 
course of a few days, and in young and feeble children they should 
be given at an early period. 

The mode of treatment recommended above is appropriate for 
that large class in whom the inflammatory element predominates. 
In a smaller number of cases the nervous element predominates 
over the inflammatory, and the treatment should be in some re- 
spects different. Such children are usually pallid and of spare 
habit, having, indeed, the nervous temperament. They are liable 
to attacks of this disease, though generally of a mild form, on 



458 PSEUDO-MEMBRANOUS LARYNGITIS. 

slight exposure to cold, and with a very moderate amount of in- 
flammation. The treatment in these cases should be directed more 
to the nervous system. My plan has been, in the treatment of such 
cases, after perhaps the use of a mild emetic, to give quinine, one 
grain three or four times daily, to a child from three to five years 
old, prescribing at the same time a simple expectorant, as syrup of 
squills, and a mildly irritating application to the throat. The 
symptoms in these cases are not severe, and active measures are 
not required, though the peculiar cough continues longer than in 
the more inflammatory forms of the disease. 

The patient with spasmodic laryngitis should be kept in a warm 
room during the paroxysms, and should inhale an atmosphere 
loaded with moisture. 

Trousseau recommends a mode of treatment of spasmodic laryn- 
gitis which was first suggested by Graves, of Dublin. It consists 
in the application underneath the chin, so as to cover the larynx, 
of a sponge soaked in water as hot as can be borne ; in ten or 
fifteen minutes it is repeated. This reddens the skin, producing 
revulsion from the larynx. The hoarseness, dyspnoea, and cough 
diminish with this treatment, and some recover without other 
measures. 

G-uersant and others speak of the importance of prophylactic 
management of children who are liable to this disease. Attention 
should be given to the dress, so that there may be sufficient 
protection from changes of temperature, and there should be an 
equable temperature of the apartments in which they reside. 
Children of a decidedly nervous temperament, in whom the 
slightest laryngitis is apt to be spasmodic, require additional 
prophylactic measures. They are pallid, and in a more or less 
cachectic state. Such children are benefited by chalybeate and 
vegetable tonics, and by exercise in suitable weather in the open 
air. 



CHAPTER III. 
PSEUDO-MEMBRANOUS LARYNGITIS. 

The term pseudo-membranous laryngitis, or true croup, is applied 
to a common and fatal disease, the essential anatomical character 
of which is inflammation of the mucous membrane of the larynx, 
with the formation upon its surface of a pseudo-membrane. It 



ANATOMICAL CHARACTERS. 459 

occurs most frequently between the ages of two and seven years. 
It is rare in adult life, and also under the age of six months. 

Causes. — There is greater liability to this disease in some chil- 
dren than in others, and occasionally the predisposition to it 
appears to be inherited. The common exciting cause is exposure 
to cold. Those children, especially, are liable to croup, who live in 
heated apartments, and are taken into the open air without proper 
covering, and those who a part of the time are warmly and a part 
of the time thinly clothed, especially as regards the covering of 
the neck. This disease is common among the poor of New York, 
who live in close rooms, overheated through the day and cool at 
night. Another less common cause is the inhalation of irritating 
vapors, or swallowing irritating or corrosive liquids. I have 
known a child to die from swallowing acetic acid, and another 
from scalding water, both having the dyspnoea and cough of true 
croup. 

This disease is ordinarily primary, but occasionally it is second- 
ary. The secondary form is not unusual in the declining period of 
measles, and it is an occasional complication of scarlet fever. Croup 
is most common in the winter months, and in times of changeable 
weather. It is said, also, that it sometimes occurs as an epidemic, 
but it is a question whether the supposed epidemics may not have 
been diphtheritic. 

Anatomical Characters. — The inflammatory action in this dis- 
ease affects not only the mucous membrane, but, in a certain pro- 
portion of cases, extends to the submucous connective tissue, caus- 
ing infiltration or oedema. The mucous membrane itself undergoes 
similar alteration to that in simple or spasmodic laryngitis, con- 
sisting of hyperaemia and thickening, proliferation, and rapid 
desquamation of its epithelial cells, and an abundant production of 
muco-pus. Sometimes the redness is found only in patches at the 
autopsy ; in other cases it extends over the whole surface of the 
larynx, while occasionally it has disappeared so that the laryngeal 
mucous membrane, though thickened and softened, presents nearly 
its normal color. In all except the mildest cases the inflammation 
extends further than the larynx, involving not only the surface of 
the pharynx, but also in greater or less degree that of the trachea 
and bronchial tubes. 

The distinguishing feature as regards the anatomical character 
of this disease remains to be noticed, namely, the false membrane 
which covers the laryngeal and often contiguous surfaces. This 
has long been considered as consisting of fibrin, which, exuding 



460 PSEUDO-MEMBRANOUS LARYNGITIS. 

in its liquid state from the submucous vessels, became fibrillated 
when exposed to the air, its interstices being filled with a greater 
or less amount of pus, epithelial cells, and amorphous matter. At 
a recent date Wagner has surprised pathologists by the statement 
that these pseudo-membranes contain no fibrin, but that they 
consist of epithelial cells, which, undergoing some form of degenera- 
tion as they are pushed forward from the mucous surface, enlarge, 
and appear under the microscope as irregular blocks interlacing 
with each other. By employing the picro-carminate of ammonia, 
or a weak ammoniacal solution of carmine, "Weber and other micro 
scopists have been able to trace the boundaries of these irregular 
and interlacing blocks, which have prolongations like the shape of 
a stag's horns, and they have observed the intermediate forms of 
transition between these and the normal epithelial cells. 

The views of Wagner are now generally admitted to be in the 
main correct as regards the pseudo-membrane of croup, but some 
of the highest authorities in pathological histology, as Rindfleisch, 
state that they find fibrin in the pseudo-membrane, in addition to 
the enlarged and degenerated epithelial cells of which it is chiefly 
composed. Rindfleisch says: "The pseudo-membrane is of a pecu- 
liarly stratified structure, since upon a layer of cells at tolerably 
equal distances there always follows a layer of fibrin, and this 
sequence is repeated from one to ten times, according to the thick- 
ness of the membrane." (Patholog. HistoL, translated, page 351.) 
As lending support to the views that the pseudo-membrane does 
contain fibrin, the fact may be stated, that while in the ordinary 
pneumonia of young children there is no fibrinous exudation 
in the air-cells, this exudation does occur, at least in a certain 
proportion of cases, in pneumonia occurring as a complication 
of croup. Thus, recently in this city, in a pneumonic lung from a 
case of fatal croup, occurring at the age of about two years, Dr. 
Francis Delafield found fibrin in the exudat of the air-cells. The 
exact nature of the degeneration which the epithelial cells undergo 
is unknown. It is generally believed that they are infiltrated by 
an albuminate, but Weber holds the opinion that the substance is 
fibrin. MM. Cornil and Ranvier, on the other hand, state: " We 
have verified the correctness of the description given by Wagner ; 
we have separated and colored the cells by means of the picro- 
carminate of ammonia, and, in consequence of the facility which 
they present of fixing the carmine, we conclude that they are not 
filled with fibrin, but rather by a matter resembling mucine. 
These exudats of true croup are pressed forward and detached in 



ANATOMICAL CHAEACTEES. 461 

proportion as the globules of pus or new epithelial cells are pro- 
duced underneath them," The pseudo-membrane varies greatly 
in amount in different cases. It may occur only in points or small 
patches, which are generally found in the vicinity of the vocal 
cords, while in other cases it extends an almost continuous mem- 
brane from the epiglottis into the bronchial tubes, and there is every 
gradation between these two extremes. It fills the orifices of the 
muciparous follicles, and the minute depressions upon the mucous 
surface, being closely adherent, so as not to be detached by efforts 
of coughing or vomiting, except in small portions. 

As the inflammation commonly extends beyond the larynx, so 
the pseudo-membrane, in a large proportion of cases, is formed not 
only upon the laryngeal, but also upon contiguous surfaces. In 
thirty-three cases of true croup, comprised in the statistics of Dr. 
"Ware, of Boston, pseudo-membranous pharyngitis was also present 
in all but one ; and in nineteen cases observed by Dr. Meigs, of 
Philadelphia, in all but three. The formation of a pseudo-mem- 
brane in the trachea in connection w ith that in the larynx is also 
common, and it is not infrequent in the bronchial tubes. M. Guer- 
sant has, so far as I am aware, collected the largest number of records 
relating to the extent of the pseudo-membrane in true croup. In 
an aggregate of 120 cases it was confined to the larynx and trachea 
in 78, or about two-thirds, while in the remainder, namely, 42, it 
extended into the bronchial tubes. 

In those whose systems are robust, the false membrane is usually 
firmer than in those whose systems are reduced. In a state of 
decided cachexia it is sometimes friable and easily detached. If 
the case continues from four to six days, it begins to soften from 
commencing decomposition, the minute fibres which attach it to 
the mucous membrane give way, and, in favorable cases, by the 
effort of coughing or vomiting it is thrown off. Separation is 
aided by muco-pus, which collects underneath. In fatal cases the 
false membrane, if detached by the efforts of the child, is rapidly 
reproduced, so that in twelve to eighteen hours the dyspnoea re- 
turns. Pneumonia not infrequently complicates croup. In extreme 
cases, in which inspiration is difficult in consequence of the obstruc- 
tion, the lungs are only partially inflated, and imperfect decarboni- 
zation of the blood and sometimes collapse of certain pulmonary 
lobules are the result. Occasionally there is that degree of thick- 
ening of the mucous membrane, and submucous infiltration, that 
the dyspnoea and danger occur more from these than from the 
presence of the pseudo-membrane. 



462 PSEUDO-MEMBRANOUS LARYNGITIS. 

Symptoms. — In some cases, pseudo-membranous, like simple laryn- 
gitis, is preceded by coryza and pharyngitis, while in others laryn- 
gitis is present from the first. The commencement of croup is 
indicated not only by fever, diminished, appetite, thirst, and such 
symptoms as accompany all acute inflammations, but by certain 
other symptoms which serve to distinguish this from all other 
diseases. 

The cough is one of the earliest symptoms which distinguish 
true croup from other laryngeal inflammations. It is hoarse or 
harsh ; its character may be expressed by the term dry or suppressed. 
It differs from the cough of spasmodic laryngitis, which is less 
hoarse and more sonorous. It is much more frequent in some cases 
than in others ; in many patients, towards the close of life, it nearly 
or quite ceases. Hoarseness of the voice is also one of the first and 
most constant symptoms, and it continues throughout. Towards 
the close of life the voice is usually lost, and the child expresses 
its thoughts in an indistinct whisper. 

The amount of expectoration varies considerably in different 
patients, according to the presence or absence of bronchial inflam- 
mation. If the inflammation extends no lower than the upper part 
of the trachea, the sputum is scanty during the whole course of 
the disease. In ordinary cases it is scanty at first, then more 
abundant, and again more scanty if the case is fatal. The scanti- 
ness of the sputum towards the close of life is due not entirely to 
exhaustion of the patient, but in part to obstruction in the larynx 
above the mucus and pus. By vomiting a much larger quantitj 7 " is 
expectorated than by the cough. Frequently small portions of 
pseudo-membrane are expectorated with the mucus and pus, and 
occasionally also larger masses, complete moulds, indeed, of the 
larynx, trachea, or even of the bronchial tubes. 

The respiration is accelerated, but not so much as in pneumonia 
or capillary bronchitis. In the advanced stage it commonly 
becomes slower than at first. As the obstruction in the larynx 
increases, the respiration assumes more and more the character 
which has been designated abdominal ; the infra-mammary region 
is depressed in each inspiratory act, while the larynx approaches 
the sternum, and the alse nasi are dilated. Patients sometimes 
have painful attacks of dyspnoea, due to detachment of an edge 
of the pseudo-membrane, and its doubling upon itself. In the 
paroxysm, the sufferer throws himself from side to side in the 
bed, or reaches his arms to his mother or nurse for relief; his 
eyes are wild, features anxious, and, in severe paroxysms, fingers 



SYMPTOMS. 463 

and prolabia livid. In the interval there is comparative quietude, 
though the respiration is constantly embarrassed. 

The frequency of the pulse varies according to the extent of the 
inflammation and the stage of the disease. In the commencement 
of primary croup it ordinarily varies from about one hundred and 
ten to one hundred and twenty beats per minute. In the course of 
the disease it becomes more frequent, and towards the close of life 
feeble. 

Xow and then a patient presents a decided remission in symp- 
toms, due to detachment of the adventitious layer, and the friends 
are apt to think that the danger is passed. Unfortunately the lull 
in symptoms is in most cases deceitful, as the cause of the dyspnoea 
is rapidly reproduced. I once attended a case in which there had 
been such dyspnoea that an unfavorable prognosis was given. 
An almost complete intermission, however, occurred in the symp- 
toms, with the exception of the febrile movement, so that a physi- 
cian who visited the patient at this time diagnosticated an essential 
fever. In a few hours, the pseudo-membrane being reproduced, 
the symptoms returned with greater violence than ever, and the 
child died. So complete an intermission seldom occurs in a fatal 
case ; and in most patients, during the times of temporary im- 
provement, there is still such dyspnoea, with the characteristic 
cough, that the nature of the disease is apparent. 

If the stethoscope is applied over the larynx in true croup, the 
loud expiratory as well as inspiratory sound is heard as the air 
passes by the obstruction. This sound is often transmitted to 
every part of the chest, so as to obscure the rales which may be 
produced there. Auscultation over the chest reveals either the 
vesicular murmur, perhaps somewhat diminished in intensity, or 
more frequently the sonorous and afterwards moist rales due to 
coexisting bronchitis. In a limited number of cases, dulness on 
percussion is observed at some part of the chest, with bronchial 
respiration, indicating pneumonia. Eecovery from croup is in 
most patients gradual ; the voice becomes less hoarse, the cough 
looser, and the dyspnoea ceases by degrees. The structural changes 
which have occurred in the mucous membrane of the larynx do 
not disappear till several days after the last pseudo-membrane is 
detached. 

Fatal cases may terminate in two or three days, but their ordi- 
nary duration is from five to fourteen days. Death may result 
directly from the thickness and firmness of the pseudo-membrane, 
which obstructs the entrance of air. Sudden death in a paroxysm 



46tt PSEUDO-MEMBRANOUS LARYNGITIS. 

of dyspnoea may occur from trie detachment of one end of the 
pseudo-membrane, and its folding upon itself. In many patients, 
death is not due so much to obstruction to the entrance of air from 
the presence of the pseudo-membrane, as to the mucus and pus 
which collect in the trachea and bronchial tubes, and which are 
not expectorated on account of the presence of the pseudo-mem- 
brane and the feeble expiratory efforts of the child. In a case 
which was examined after death in the Nursery and Child's Hos- 
pital of this city, the false membrane was apparently not sufficient 
to produce a fatal result, but the air-passages below it were nearly 
filled with muco-purulent matter, which obstructed the entrance of 
air. 

Pathological Characters. — This disease is then essentially a 
laryngitis presenting the lesions of a simple though usually severe 
mucous inflammation, but with a superadded element, namely, the 
false membrane. The coexistence of simple or pseudo-membranous 
pharyngitis, tracheitis, and bronchitis is also, as we have seen, 
common. The impediment to respiration, which renders croup so 
dangerous and fatal, is due not only to the presence of the false 
membrane, but to the mucus and pus which collect below it, and 
also to the inflammatory swelling of the mucous membrane and 
submucous oedema. In addition, there is a neuropathic element 
which increases the dyspnoea, and which most observers consider a 
spasmodic contraction of the laryngeal muscles induced by the in- 
flammation, and hence the easier breathing in sleep, and in the 
general muscular relaxation, Avhich precedes death. Prof. Jacobi 
(Amer. Journ. of Obstet.,ete.,N. Y., May, 1868), however, holds that 
the state of these muscles is one of paralysis rather than spasmodic 
contraction. In his opinion, this paralysis " is secondary. It de- 
pends on the oedematous soaking of the posterior crico-arytenoid 
muscles following the oedema of the mucous membrane of the 
crico-arytenoid folds." 

In several fatal cases which I have had an opportunity to exam- 
ine after death, I have found the appearance of the lungs quite 
uniform. They were reduced in volume (semi-collapsed) and more 
or less congested. Certain parts distant from the bronchi, espe- 
cially the edges and thin portions, were collapsed completely, and 
certain lobules also hepatized. I have also observed, though in 
some of the cases my attention was not directed to it, distension 
of the right cavities of the heart with blood, and large thrombi. 
From the nature of the disease, the blood is less oxygenated, and 



DIAGNOSIS — PROGNOSIS. 465 

somewhat darker than in those who die of diseases not involving 
the respiratory apparatus. 

Diagnosis. — The diagnosis of true croup is ordinarily easy. It 
might be mistaken for spasmodic laryngitis, but more frequently 
spasmodic laryngitis is mistaken for it. The differences which 
will aid in differential diagnosis are the following : commencement 
abrupt and at night in one, gradual in the other ; presence in one, 
absence in the other, of a pseudo-membrane upon the surface of the 
fauces ; fragments of this membrane in the sputum in one ; charac- 
ter of the cough ; course of the disease growing gradually worse 
in one, in the other, with few exceptions, rapidly improving. Trous- 
seau speaks of the liability to error of diagnosis in those cases in 
which spasmodic laryngitis is associated with pseudo-membranous 
pharyngitis. Few physicians hesitate to designate as true croup 
those cases in which there is a croupal cough in connection with 
false membrane upon the surface of the fauces, and yet the laryn- 
gitis under such circumstances may be merely spasmodic. This 
coexistence of pseudo-membranous pharyngeal and of spasmodic 
laryngeal inflammation is, however, probably rare, but its occa- 
sional occurrence should be borne in mind. 

True croup is readily distinguished from laryngismus stridulus, 
or internal convulsions. Laryngismus stridulus is a purely nerv- 
ous affection ; it occurs suddenly, causing great dyspnoea, or momen- 
tary suspension of respiration, without the fever and without the 
hoarse voice and cough of croup. "When muscular relaxation oc- 
curs, the attack ceases. The difference between the two diseases is 
therefore obvious. 

Prognosis. — The great mortality from true croup is universally 
known, and those physicians who report a large number of favor- 
able cases have probably mistaken spasmodic croup for this disease. 
According to the statistics of Dr. "Ware, nineteen out of twenty 
die; but with judicious treatment, commenced early, the mortality 
is probably less than this, though still great. Increase of dyspnoea, 
the voice and cough becoming more hoarse, and the pulse more 
accelerated, indicate a fatal form of the disease. Attention has 
already been called to temporary improvements which are apt to 
occur in croup, and lead to an error in prognosis. However, im- 
provement continuing more than twelve hours is evidence of the 
decline of the disease. 

The near approach of death is shown by lividity with great rest- 
lessness, or by pallor and somnolence. If the patient recover from 
croup, there often remains more or less bronchitis or broncho-pneu- 
30 



466 PSEUDO-MEMBRANOUS LARYNGITIS. 

monia, which requires treatment, and the laryngitis when its 
pseudo-membranous character is lost, persists for a time, causing 
more or less hoarseness and acceleration of pulse. 

Treatment. — The importance of early treatment in this disease 
has been sufficiently alluded to. If it has continued two or three 
days when first recognized, the chance of recovery is greatly dimin- 
ished. As the danger in true croup arises from the presence of the 
pseudo-membrane, the indication is to prevent its formation, so far 
as possible, and to aid in its removal when formed. 

Emetics have been and are still much prescribed in the treatment 
of this disease. Properly employed, they produce a good effect, 
but much harm has been done by their injudicious administration. 
As a rule, the depressing emetics should not be given except at the 
commencement of the disease, not later, indeed, than the second 
day, and not given at all if the patient is feeble or cachectic, or if 
the croup is secondary, as when it occurs in connection with 
measles or diphtheria. I have known death occur almost imme- 
diately after the administration of an antimonial emetic in the 
pseudo-membranous laryngitis accompanying diphtheria, when 
there was no urgent dyspnoea. 

At the commencement of croup, ipecacuanha or tartrate of 
antimony and potassa may then be prescribed if the disease is 
primary, and the patient in good general condition ; but if it is 
secondary, or the vital powers at all reduced, an emetic which is 
less depressing is preferable, as turpeth mineral or sulphate of copper. 
The emetic promotes the secretion of mucus, and a considerable 
quantity of this substance is usually found in the vomited matter, 
and it may also cause the detachment and expulsion of the softer 
portions of the pseudo-membrane. If the child in the initial stage 
of croup is under the age of three years, the syrup of ipecacuanha, 
with or without alum, may be administered in teaspoonful doses 
at intervals of ten or fifteen minutes till the emetic effect is pro- 
duced, or if the age is above three years, the compound syrup of 
squills may be employed instead. But when assured that a pseudo- 
membrane is forming, I prefer in most cases the sulphate of copper 
in one or two grain doses given in powder with an equal quantity 
of ipecacuanha, and repeated in ten minutes if the first dose does 
not produce the desired emetic effect. There is in most cases more 
or less relief of the symptoms after the emesis, though it may be 
but temporary. In one case recently in my practice, in which there 
was at the first visit considerable dyspnoea, distinct croupy cough, 
and a pseudo-membrane on both sides of the fauces, and in which 



TREATMENT. 467 

I had made an unfavorable prognosis, the parents observing the 
good effect of the first powder, repeated the medicine, contrary to 
directions, at intervals of about two hours, till my visit on the 
following day, and the patient recovered. Two or three powders 
are, however, ordinarily sufficient for this preliminary treatment. 
Turpeth mineral is not inferior in its effects to sulphate of copper, 
and many physicians of ample experience prefer it, given in doses 
of two or three grains. Prof. Fordyce Barker, of this city, who 
prescribes an emetic of turpeth mineral immediately on being 
summoned to a case, states that he has not lost a patient thus 
treated for many years. After prompt and efficient emesis is pro- 
duced, other measures are required. We will speak hereafter of 
the further employment of emetics during the progress of croup. 
Loss of blood is not required in the treatment of croup. The 
stronger cardiac sedatives, as aconite and veratrum viride, may 
occasionally be advantageously employed on the first and second 
days of primary croup. They should only be administered to 
those that are robust. They should not be prescribed after the 
pseudo-membrane is fully formed, nor in cases of secondary croup. 
Unfortunately the emetic treatment recommended above, and 
which must be considered preliminary, fails to arrest the disease 
in a large proportion of cases. It does seem to diminish the 
amount of false membrane in certain cases, and there is reason to 
think that it may even in some instances prevent its formation, 
so that the inflammation remains a simple laryngitis, though pre- 
senting in its commencement the characteristic symptoms of croup; 
but in other and a large proportion of cases the pseudo-membrane 
becomes fully formed, and continues to increase. The profession have 
been long looking for a remedy which, taken internally, may, by its 
effect upon the blood or the inflamed surface, prevent or diminish 
the membranous formation, and also for a remedy which, employed 
topically, may liquefy and remove it. The remedy which has been 
and still is most frequently prescribed for the first of these purposes 
is calomel. The ordinary ill-effects of this agent, namely, stomatitis 
and ptyalism, should not deter from its employment if it exerts any 
controlling influence over a disease so rapid and fatal as true croup. 
I am of opinion that it is useful unless there is that degree of 
impoverishment of the blood and cachexia which would contra- 
indicate the continued use of any depressing agent. Calomel 
probably has no effect upon the false membrane ; but it is to be recol- 
lected that there are other factors in the production of the dyspnoea 
which it is probable that calomel does aid in removing, whether 



468 PSEUDO-MEMBRANOUS LARYNGITIS. 

by its derivative effect on the intestinal surface, or by some other 
mode of action not fully understood. Calomel is believed to be one 
of the most efficient agents, administered internally, for removing 
the thickening and infiltration of the laryngeal mucous membrane 
and the submucous oedema. I think that I have observed benefit 
from its employment, whether in a single dose of six to ten grains, or 
in small doses of one-fourth to one grain repeated several times in 
twenty-four hours. The calomel may be administered alone, or with 
ipecacuanha not in sufficient quantity to cause emesis, or in certain 
cases with Dover's powder. It may be given from two to four 
days, perhaps sometimes longer, when it should be followed by a 
mixture of chlorate of potassa or soda and muriate of ammonia 
given frequently. In cases in which the vital powers are reduced, 
especially in secondary croup, this mixture should be given from the 
first, in place of calomel. The chlorate has a solvent effect, though 
feeble, on pseudo-membranes, and as when taken into the system it is 
known to be eliminated in most of the secretions and excretions, 
it is not improbable that it escapes also from the surface of the 
larynx in the mucus, and therefore comes in contact with the mem- 
branous formation. The chlorates in frequent large doses some- 
times cause salivation. Probably the effect of the muriate is 
subordinate, but it is believed by therapeutists to increase the muco- 
purulent secretion, and therefore diminish in some degree the 
turgescence of the mucous membrane. Cases in which there is 
marked and protracted dyspnoea and croupal cough do now and 
then recover with the use of chlorate of potassa or soda and mu- 
riate of ammonia, either employed after calomel, or without it as 
the main remedy from the commencement of the disease — so many, 
indeed, that it cannot be doubted that they do have some curative 
effect. The following formula may be employed for a child from 
three to five years of age : — 

R. Potas. chlorat. 5j ; 
Amnion, niuriat. 9ij ; 
Syr. simplic. sj ; 
Aquae §ij. Misce. 

Dose, one to two teaspoonfuls every half hour or hourly, accord- 
ing to the urgency of the symptoms. This should be continued 
regularly night and day until the cough becomes looser, or until it 
is evident from the unfavorable nature of the case that it can be 
of no further service. 

A very important part of the treatment is the inhalation of 
steam. Some of our most experienced physicians consider this 



TREATMENT. 469 

more useful than all other measures combined. In one of the most 
severe cases which I have met, which terminated favorably, the 
room was so filled with steam that water hung in drops from the 
ceiling. The atmosphere which the child breathes should be con- 
stantly loaded with moisture, without, however, that degree of 
heat which would add materially to the discomfort of the patient 
or attendants. Moist warm air coming in contact with the in- 
flamed surface promotes expectoration and renders the cough 
looser. Steam may be readily produced by placing heated irons 
or bricks in a shallow pan or pail containing a little water, by 
pouring water upon a heated surface, or by a spirit-lamp or gas- 
jet under a pan of water. In order to avoid heating the entire 
room and to concentrate the vapor, the nurse may sit with the 
child under a frame covered with a blanket, and the steam be pro- 
duced underneath. 

A temperature of 75° or 80°, if the atmosphere is loaded with 
moisture, is more readily tolerated than a lower temperature with 
a dry atmosphere, and a temperature at least as high as 75° is 
required, or too much of the vapor is deposited. Of late, the in- 
halation of the spray of lime-water has been recommended, in the 
belief that it exerts a solvent effect upon the false membrane. 
The atomizer has been employed in order to produce the spray, 
but difficulty attends its use for children. It has been still more 
recently recommended to add to the water which is employed for 
the purpose of producing steam one or two lumps of quicklime, 
and allowing them to slake. The vapor by this means becomes 
impregnated with particles of lime. This last mode of employing 
lime may partially obviate the principal objection which has been 
raised against the use of steam in the treatment of croup, namely, 
that it necessitates confining the air, which soon becomes loaded 
with carbonic acid, since slaked lime, when moistened, rapidly 
absorbs this gas. 

The employment of lime by inhalation in this disease certainly 
merits further trial, although, in the few cases in which I have 
employed it in both the ways stated above, I have observed no 
decided benefit from its use. 

It has already been stated that depressing emetics should not 
be employed after the second day, but a period arrives in most cases 
when another class of emetics are required. They are required 
when the dyspnoea is urgent, as a means of removing from the air- 
passages the collection of mucus and pus and portions of false 
membrane which mav be detached. Those emetics should now be 



470 PSEUDO-MEMBRANOUS LARYNGITIS. 

prescribed which operate promptly with the least depression. 
Sulphate of copper is one of the best, if not the best, for this stage 
of croup, and it is usually employed by physicians. A child of 
five years may take one grain dissolved in a little water, and the 
dose be repeated if required in ten minutes. Sulphate of zinc or 
turpeth mineral may be used in the place of the copper. Dr. J. 
P. Meigs, of Philadelphia, prefers pulverized alum given in tea- 
spoonful doses, but it is less efficient, and I am not aware that it 
possesses any advantages over the sulphate of copper. "Whatever 
emetic is employed, its operation may be promoted by draughts of 
warm water. 

It is to be recollected in the treatment of croup that the pseudo- 
membrane, by commencing decomposition, and by the pus and 
mucus which collect underneath, is more easily detached after a 
few clays, if the patient lives, than at first. Therefore the phy- 
sician should endeavor to sustain the vital powers, in order that 
the cough may have sufficient force to separate this substance as 
soon as its fibres of attachment begin to loosen. A patient with 
croup rarely takes solid food, but he should be allowed beef-tea, 
milk, and farinaceous drinks at short intervals. If there are signs 
of exhaustion, alcoholic stimulants are proper, and fresh air should 
also be allowed so far as is compatible with the inhalation of steam. 
"While these general measures are employed, local treatment 
should not be neglected. The profession are not agreed as to the 
treatment either external or internal of the throat. As to external 
treatment, some recommend poultices, others cold applications, and 
others still, irritants. Professor Peaslee, of this city, in a series of 
papers on the pathology of croup, published in the American 
Medical Monthly, 1854, says of cold applied externally: "We con- 
sider this of the greatest value and importance. If cold applications 
are efficacious in all cases of external inflammation, they are 
scarcely less so here, where the inflamed surface is so nearly super- 
ficial. Cold must, however, be continuously applied to produce 
the desired effect. Applied at intervals, indeed, it rather promotes 
than retards the inflammatory process ; since during the intervals the 
temperature rises above the normal standard, in consequence of the 
reaction of the chill on the surface. Cold water may be constantly 
dropped from a sponge upon a compress laid over the throat of the 
child ; and the latter should be of only one or two thicknesses of 
linen, that evaporation may go on as rapidly as possible." 

In ordinary cases cold applied over the larynx is preferable to 
poultices or warm applications. The sides of the neck should be 



TREATMENT. 471 

kept warm by pieces of pork, or one or two thicknesses of flannel, 
while in the interspace in front, over the larynx, a compress of 
muslin or linen squeezed from ice-water should be applied every 
five or ten minutes. These may be retained in place by a single 
thickness of muslin passing around the neck, and cut narrow in 
front, in order to facilitate the applications of the compress. In 
place of the compress, a small quantity of crushed ice may be em- 
ployed, surrounded by oil-silk to prevent dripping. This mode of 
applying cold I have found to be more convenient, on account of 
the frequent restlessness of the child, than that recommended by 
Prof. Peaslee. Cold is especially serviceable if the child is robust, 
with flushed cheeks and full and rapid pulse. In secondary croup, 
or croup occurring in feeble states of system, or presenting a sub- 
acute character, poultices or fomentations to the neck, with mode- 
rate irritation, may sometimes give most relief. 

Topical treatment of the fauces and larynx has long been re- 
commended in croup, and the agent which has been most fre- 
quently applied is nitrate of silver in solutions varying in strength 
from ten to forty grains to the ounce. It is applied once, twice, 
or several times daily. Nitrate of silver does not dissolve the 
pseudo-membranes, but it contracts those with which it comes in 
contact, and by the contraction aids in their detachment. 

Great difficulty, however, attends the application of the probang 
to the larynx of the child, on account of his struggles and resist- 
ance, and it may well be doubted whether the most skilful opera- 
tors usually succeed in applying it to the interior of this organ. 
But if the instrument is pressed against the aperture of the glottis, 
some of the liquid trickles from the sponge into the larynx, as is 
indicated by the severe coughing which it produces. Of late years 
three other substances have been used for topical treatment of the 
throat, which appear to be more effectual in removing the pseudo- 
membrane and controlling the inflammation. One is liquor ferri 
subsulphatis, another carbolic acid, and the third bromine. The 
liquor ferri subsulphatis is best employed with glycerine in the 
proportion of one part to four. 

R. Liq. ferri subsulphatis 5j ; 
Glycerinse Jss. Misce. 

Carbolic acid, in its crystalline or undiluted state, is an active 
caustic, with a tendency to spread. It should be used considerably 
diluted with water. 

R. Acid, carbolic. f5ss ; 
Aquae ^v. Misce. 



472 PSEUDO-MEMBRANOUS LARYNGITIS. 

Bromine has only recently been employed for topical treatment 
of pseudo-membranous inflammations. It is used in conjunction 
with bromide of potassium. 

I£. Brominii ^ij ; 

Potass, bromid. gr. xiy; 
Aquae ^j. Misce. 

This is called the bromine solution, but it must be considerably 
diluted for use. Twenty-four to forty drops should be added to 
an ounce of water for application to the fauces or larynx. There 
are physicians who highly extol each of these three agents in the 
treatment of croup as well as diphtheria. They are probably all 
useful, though I cannot speak from personal observation in refer- 
ence to the effect of bromine. They should be applied in the same 
manner as nitrate of silver, to which either one is probably prefer- 
able. Of the three agents, the one which I can highly recommend 
from personal experience for those cases which require this mode 
of treatment, is the subsulphate of iron. Local treatment, as re- 
commended above, is obviously most useful in those cases in which 
there is decided inflammation of the faucial surface attended with 
patches of false membrane, or those cases in which the inflamma- 
tion is first pharyngeal and becomes laryngeal by extension. 

Unfortunately, as I have already stated, true croup, whatever 
the therapeutic treatment, is, in a large proportion of cases, a pro- 
gressive disease. The hoarseness of the cough and voice and the 
dyspnoea gradually increase. The pulse, becoming more frequent 
and feeble, indicates the need of the most nutritious food, as the 
animal broths, and of alcoholic stimulants. The danger is, how- 
ever, from the dyspnoea rather than asthenia. Medicine has failed 
to check the disease, and shall now the expedients of surgery be 
tried — shall tracheotomy be performed ? 

The published statistics relating to tracheotomy in croup are to 
a considerable extent unsatisfactory, since we are not informed, as 
regards most of them, at what stage of the disease the operation 
was performed, and what were the evidences of a fibrinous exuda- 
tion. The most valuable and reliable statistics bearing upon this 
subject, so far as I am aware, are those published by Prof. Jacobi, 
of this city, in the American Journal of Obstetrics, etc., for May, 
1868, and containing the results of the cases which were operated 
on by himself and Drs. Krackowizer and Yoss. These gentlemen 
are known to the profession of New York as careful and judicious 
practitioners, not likely to operate when there was probability of 
success by therapeutic measures, and not likely to mistake simple 



TREATMENT, 



473 



or spasmodic laryngitis for true croup, 
tistics of their operations : — 

Age. 
Under 2 years 
From 2 to 3 years 

" 3 to 4 " 

" 4 to 5 " 

" 5 to 6 " 

" 6 to 7 " 

" 7 to 8 " 
10 " 
Not given 



I have tabulated the sta- 



umber. 


Kecovered. 


Died 


8 


1 


7 


29 


5 


24 


26 


4 


22 


34 


11 


23 


9 


2 


7 


1 


1 





3 





3 


1 





1 


55 


15 


40 



166 



127 



Time of death after 


Number of 


Time of Death after 


Number of 


operation. 


cases. 


operation. 


cases. 


"Within 24 hours 


19 


On 5th day 


9 


On 2d day 


7 


" 6th " 


4 


" 3d " 


16 


" 7th " 


2 


" 4th " 


15 


" 9th " 


1 






From 10th to 31st 


day 5 


Total 






78 



The following were the causes of death, as given in the records 
of 73 cases : — 



In operation 


1 


Pneumonia 


Apnoea from too late operation 


6 


Broncho-pneumo. &pulm. gang 


Apncea .... 


3 


Pulmonary oedema 


Anaemia and exhaustion . 


4 


Pseudo-membranous bronchitis 


Diphtheria 


8 


Tuberculosis 


Bronchitis 


6 


Convulsions 


Broncho-pneumonia . 


15 


Emphysema 



Total 



1 

18 
1 
2 
2 

73 



The following table gives the result of tracheotomy in one hun- 
dred cases. It is prepared from the statistics of Giiterbach, lately 
published : — 





Age. 


Eesult. 


Under 1 year 


1 case fatal 


Between 1 and 2 years 


t( EC 


i< 


2 and 3 " 


33^- per cent, recovered 


(< 


3 and 4 " 


40 


l( 


4 and 5 " 


38^ « 


u 


5 and 6 " ... 


44| 


C( 


6 and 8 " ... 


14f « 


u 


8 and 9 " 


25 " 



From conversations which I have had with surgeons of New 
York, I am persuaded that the above tables present a more favor- 



474 PSEUDO-MEMBRANOUS LARYNGITIS. 

able result than could be furnished by the general surgical practice 
of this city. Most ~New York surgeons, however, seem to shun the 
operation and regard it with ill-favor, and did they operate as fre- 
quently as those whose names I have mentioned, possibly the re- 
sult would be better. Statistics in Paris probably give nearly the 
true proportion of successful and unsuccessful operations of tra- 
cheotomy for croup, as it is performed by skilful and careful sur- 
geons. Of 388 cases occurring in the practice of several Parisian 
surgeons, 346 died and 42 recovered ; while in the Hopital Sainte 
Eugenie, of 374 operated on, 310 died. (Bouchut.) 

The facts in reference to tracheotomy in croup are the following : 
The majority of those operated on do not recover, but some live 
w r ho without the operation would die. The operation is now more 
successfully performed than formerly, as the conditions of success- 
ful operation are better understood. Those who have operated 
several times, confess that their last cases did better than their 
first. Trousseau's experience was striking and instructive in this 
respect. ~No one, probably, ever performed this operation for croup 
more times than he, and, from constantly greater success, he be- 
came more and more an advocate of the operation. Tracheotomy, 
if properly performed, does not in any case shorten life, but it 
frequently prolongs it several days. It diminishes greatly the 
dyspnoea, and renders death easy. 

The objections to the operation are partly of a moral nature. 
The parents, already in the extreme of grief on account of the 
suffering and probable death of the child, consent with reluctance 
to an operation which promises not cure, but a prolongation of life. 
Common sympathy with the child and regard for the emotions of 
the parents should certainly have an influence in deciding for or 
against the operation. The first case of tracheotomy which I 
witnessed was such as, if common, would condemn this operative 
measure entirely. No anaesthetic was given, and, in the midst of the 
struggles of the child, large veins were severed, from which an abun- 
dant hemorrhage occurred. The trachea was opened, but this was 
no sooner done than death occurred, partly from the loss of blood, 
and partly from the obstruction to respiration caused by its entrance 
into the bronchial tubes. Such cases are, however, quite exceptional. 
Death rarely occurs during the operation, unless the patient is al- 
ready moribund, and the possibility of such a result should have 
little weight in our decision for or against the operation. 

Few will deny, in the light of statistics, that tracheotomy is, 
in certain cases, proper, and that a physician at times would be 



TREATMENT. 475 

culpable if he did not strongly urge its performance. There are 
certain supposed contraindications. One is age less than two years. 
It is true that those under the age of two years are less likely to 
recover after the operation than those above that age ; still, trache- 
otomy has now and then saved the lives of the youngest infants 
who have croup. The possibility, therefore, of success justifies 
the performance of the operation, however young the infant, when 
the only alternative is death. In the foregoing statistics it is seen 
that one of eight recovered who were under the age of two years. 

The presence of capillary bronchitis or pneumonia does not posi- 
tively contraindicate tracheotomy, though it diminishes greatly 
the chances of a favorable issue. Nor is tracheotomy forbidden 
by the extension of the false membrane into the bronchial tubes, 
since it diminishes the amount of obstruction along which the air 
passes in order to reach the lungs, and the muco-pus as well as 
pseudo-membrane, lying below the point of operation, may be 
expectorated through the aperture. A decidedly asthenic state, 
as after measles or scarlet fever, indicated by feeble pulse and other 
symptoms of exhaustion, may or may not contraindicate the ope- 
ration, whether the pseudo-membrane is limited to the larynx and 
trachea or is more extensive. 

The manner of performing tracheotomy and the subsequent 
treatment pertain to surgery, and are described in surgical works. 
A skilful surgeon should, indeed, be employed to perform the 
operation when it is practicable. At what time in the course of 
the disease tracheotomy should be resorted to is an important 
practical question. Trousseau at one time recommended it as 
soon as there were certain evidences of the presence of a pseudo- 
membrane, but in the latter part of his life he did not operate so 
early. The correct rule, in my opinion, is not to operate till there 
are signs that the blood is not sufficiently oxygenated, such as 
lividity of the prolabia and tips of fingers. When these signs 
occur, it is unsafe to delay long. The arrangements should be pre- 
viously made, that no time be lost. 

It is an interesting fact that a large proportion of those who 
die after tracheotomy die of bronchitis, usually capillary, or of 
pneumonia developed after the operation. These diseases seem to 
be partly attributable to the operation, or, if previously existing, 
to be aggravated by it. It is believed that the introduction into 
the bronchial tubes and the lungs of cool air, of air not warmed by 
the natural circuit through the nostrils and larynx, may be a cause 
of these inflammatory complications. Sometimes, also, the canula 



476 BRONCHITIS. 

by pressure increases the inflammation of the surface on which it 
lies. Therefore, not only does the operation require skill in its 
performance, hut much of its success depends on the subsequent 
management. After the operation, the temperature of the apart- 
ment should be kept constantly at from 85° to 90°, and loaded 
with moisture. This obviates in part, but only in part, the tendency 
to bronchitis and pneumonia. Constant attention should be given 
to the canula, to prevent its filling with mucus and pus. Trousseau 
employed a double canula, which can be readily cleaned by removing 
the internal cylinder. The nurse, when properly instructed, can 
remove this cylinder as often as may be necessary in order to clean 
it. Mr. Lawrence, of London, and, following him, some other 
surgeons, prefer not to use the canula. The edges of the wound 
are kept apart' by a wire which passes around the neck, or a little 
of the trachea is removed so as to produce a sufficient aperture. 
The reader is referred for particulars regarding this mode of ope- 
rating to recent treatises on operative surgery. 

After the operation no more medication is required. The patient 
should be kept quiet and free from excitement. His diet should 
be mainly liquid, and of the most nourishing character. In a few 
days, if the symptoms abate, the aperture may from time to time 
be closed with the finger after the withdrawal of the canula, in 
order to ascertain if the larynx is free from obstruction. If bron- 
chitis or broncho-pneumonia arise, the oil-silk jacket, with counter- 
irritation to the chest, is required, and stimulating expectorants, as 
carbonate of ammonia and syrup of senega, should be ordered. 



CHAPTER IY. 

BRONCHITIS. 

Inflammation of the bronchial tubes, or bronchitis, is probably 
the most frequent disease of early life. It is usually associated 
with more or less inflammation of the mucous membrane of the 
nostrils, larynx, and trachea. We designate the disease coryza, 
laryngitis, or bronchitis, according as one or the other inflamma- 
tion predominates. Sometimes bronchitis occurs with but slight 
inflammation elsewhere, and often the coryza and laryngitis abate 
while the bronchitis is still active. 



BRONCHITIS. 477 

Bronchitis occurs both as a primary and secondary disease. The 
secondary form is common in connection with measles, hooping- 
cough, pneumonia, and pulmonary phthisis, and it is not uncom- 
mon in scarlet fever, variola, remittent and continued fevers. 
Bronchitis is mild or severe, and acute, subacute, or chronic. If 
the inflammation affects the bronchules, the bronchitis is called 
capillary. Bronchitis is usually bilateral, affecting the tubes on 
the two sides with about equal intensity. The exceptions are 
when it is dependent on pneumonia or pulmonary phthisis. In 
these cases it is confined to those tubes, or nearly to those, which 
are surrounded by the tubercular or inflammatory product. 

Causes. — The causes of secondary bronchitis are obviously the 
diseases in connection with which it occurs. The cause of primary 
bronchitis is the same as that of simple acute laryngitis or coryza, 
namely, sudden change of temperature from warm to cold, exposure 
to currents of air, the practice of sending children without suffi- 
cient clothing from heated rooms into the open air, the throwing 
off of bedclothes at night, etc. Dentition is also an occasional 
cause, since some children have attacks which coincide with the 
eruption of the teeth. The cough of dentition is usually purely a 
nervous affection ; but in other instances it is accompanied by 
more or less mucous secretion, and is evidently dependent on a 
mild inflammation. 

Anatomical Characters. — In the most common form of bron- 
chitis, the larger bronchial tubes only are affected. They are the 
seat of the inflammation in most of those cases' which are desig- 
nated " colds" by families, and which are often treated without 
the aid of the physician. The lining membrane of the bronchial 
tubes presents the ordinary anatomical characters of mucous in- 
flammations. It is reddened uniformly or in patches, intensely, or 
in that milder degree known as arborescence, according to the 
severity of the inflammation. 

The secretion of the muciparous follicles is at first arrested, and 
the surface of the membrane is dry. In the course of a day or 
two the secretory function is re-established, and the surface is 
covered with thin and transparent mucus. A day or two later, the 
secretion becomes thicker, consisting of mucus and pus. Mixed 
with these substances are epithelial cells, which are exfoliated in 
abundance from the inflamed surface. At the same time the 
mucous membrane becomes thickened and more or less softened. 
If the inflammation is severe, the vessels of the submucous cellular 
tissue are also injected. 



478 BRONCHITIS. 

Usually, in about a week in the young child, in from one to two 
weeks in older children, the inflammation begins to abate. Gradu- 
ally the inflamed membrane returns to its normal consistence, 
thickness, and vascularity, and with this return to the healthy 
state the muco-purulent secretion abates. 

In this, which is the simplest form of bronchitis, and most com- 
mon, there is no ulceration, and rarely any pseudo-membranous 
formation, if the disease is idiopathic. Pseudo-membranous bron- 
chitis is not unusual as an accompaniment of pseudo-membranous 
laryngo-tracheitis. 

Were bronchitis limited to the larger bronchial tubes, it would 
indeed be a simple affection, but unfortunately it has a tendency 
to extend downwards. Commencing in the larger, it gradually 
invades the smaller tubes in a similar manner to the extension of 
erysipelas upon the skin. More rarely the inflammation com- 
mences simultaneously in the larger and smaller tubes. !N~ow the 
gravity of bronchitis is proportionate to the degree of its exten- 
sion downwards. It may stop at any point in its progress, but if 
it reach the smaller tubes it is one of the most serious affections 
of early life, that already alluded to, namely, capillary bronchitis. 

The mucous membrane of the minute tubes, those next to the 
air-cells, is delicate, with but little submucous connective tissue, 
and it frequently, at post-mortem examinations, does not present to 
the eye those distinct inflammatory changes which are observed in 
tubes of large diameter. It is sometimes not notably thickened, 
nor its vascularity much increased, even when there is reason to 
believe from the symptoms that it was the seat of active phlegmasia. 
As we pass from these minute tubes to those of larger calibre, the 
inflammatory lesions become more distinct. The inflammation 
produces minute and abundant points of redness, and the membrane 
is evidently thickened ; often it is rough or granular. 

The minute bronchial tubes are very small, especially under 
the age of three years, and since in capillary bronchitis a large 
proportion of them are inflamed, the source of the danger is 
apparent. It is with difficulty that the patient with capillary 
bronchitis can, by the effort of coughing, free the tubes from the 
secretions which are constantly collecting in them. In weakly 
children, under the age of two years, expectoration is most difficult, 
and hence the great and increasing dyspnoea from which such 
patients suffer. 

In unfavorable cases of capillary bronchitis, the following changes 
are apt to occur. The small tubes, usually those in the posterior por- 






ANATOMICAL CHARACTERS. 479 

tion of the lungs, become more and more loaded with mucus and 
pus, obstructing the entrance of air till, finally, one after another of 
the lobules cease to be inflated. As the air passes out of the air-cells 
of a lobule more readily than it enters them, partial lobular 
collapse occurs. Doubtless, also, some of the mucus and pus, no 
longer expectorated, is forced backward into the air-cells. 2sTow, a 
portion of lung from which air is excluded while the circulation 
continues, becomes congested. If the lungs of a patient who has 
died at this stage of capillary bronchitis are examined, the ante- 
rior portions will be found to present nearly their normal appear- 
ance, while the lobular changes which have been described will 
be found mainly in the posterior part. Certain of the lobules will 
be observed depressed below the common level, of a dark red color 
from passive congestion, firm to the touch, and non-crepitant or 
feebly crepitant. Sometimes only a few of the lobules have under- 
gone this change of collapse and congestion, but more frequently a 
considerable number on both sides are affected. 

Up to this time there is often no pneumonia, but this is the state 
of luno-s and bronchial tubes which has sometimes been mistaken 

CD 

for and designated broncho-pneumonia. It has also been called 
lobular pneumonia. The substance which fills the bronchial tubes is 
usually muco-purulent,but in exceptional cases, in addition to mucus 
and pus, there is more or less fibrin. This ordinarily occurs as a 
delicate film of small extent, observed here and there, and readily 
detached from the surface underneath. In rare instances it occurs 
as a firm and continuous membrane, forming a mould of the tubes, 
increasing greatly the dyspnoea, and constituting a true bronchial 
croup. 

If the patient survive the immediate effects of capillary bron- 
chitis, the inflammation of the mucous membrane soon begins to 
abate. The collapsed and congested lobules, and the terminal 
portions of the bronchial tubes leading to them, which are ob- 
structed by inflammatory products, ordinarily return to their nor- 
mal state as the inflammation declines, but in other instances they 
undergo changes which are interesting, but which are not fully un- 
derstood. When the function of a portion of lung ceases, as it does 
when the air is excluded from it, the cells and nuclei which it con- 
tains, and probably other parts, begin to undergo fatty degeneration. 
These elements become granular, somewhat enlarged and opaque, 
and here and there mixed with them are other large cells filled 
with oil globules. These are the compound granular cells of patho- 
logists, and, occurring in this situation, are produced by metamor- 



480 BRONCHITIS. . 

phosis of the epithelial cells. They are epithelial cells which have 
progressed more rapidly than others in fatty degeneration, having 
reached that stage of it which immediately precedes liquefac- 
tion. "We often with the microscope observe not only these cor- 
puscles, but their fragments as they are dissolving. These changes 
are common in lobules which are for a certain time collapsed and 
congested, whether or not pneumonia has supervened. 

If the lobules remain collapsed for a considerable period on 
account of the feeble inspiratory efforts of the child, and the pre- 
sence of mucus and pus which obstruct the tubes, they may undergo 
such change that they are not inflated, even when the tubes be- 
come freed from obstruction. If an opportunity is presented of 
examining the lungs at this time, it will be found difficult, if not 
impossible, to expand, even by strong insufflation, the lobules 
which have been for a considerable period collapsed and more or 
less congested. These lobules have a greater specific gravity than 
water, and closely resemble lobules which are solidified by inflam- 
mation; but when the changes occur which have been detailed 
above, there is obviously no true pneumonia at first. 

Pneumonia is, however, a not infrequent complication and result 
of capillary bronchitis. "While in certain lobules collapse and 
simple congestion occur, others may be affected by a true inflam- 
mation extending from the adjacent inflamed tubules. Therefore 
in fatal cases it is not unusual to find in the same lung lobules 
collapsed and congested, and others hepatized. In the former 
there is diminution in the size of the alveoli, with simple conges- 
tion, while in the latter the alveoli are of full size, or distended in 
consequence of the abundant proliferation of cells within them. 
Pneumonia may also occur as a sequel of capillary bronchitis in 
lobules, which in consequence of the feebleness of the infant, or 
other cause, remain collapsed and congested, since tissues remain- 
ing in a state of passive congestion are very prone to inflammation. 
That pneumonia, subacute and catarrhal, does occur in the collapsed 
lobules, is demonstrated by the fact of a proliferation of cells with- 
in the alveoli. 

Minute abscesses, usually directly under the pleura, have occa- 
sionally been observed at the autopsies of those who have recently 
had capillary bronchitis, and pathologists are not agreed as to the 
mode in which they are produced. Some of them, if not all, are 
evidently connected with the minute bronchial tubes, and the 
quantity of pus contained in each is not usually more than one or 



SYMPTOMS. 481 

two drops. The most reasonable view of their causation is that 
they are produced in the terminal tubes where the mucus and pus 
collect. The pus acts as an irritant and causes inflammation, and 
the inflammation increases the quantity of pus. The walls of the 
tube which is now the seat of an abscess are destroyed by ulcera- 
tion, and probably, also, some of the contiguous air cells. The 
little cavity is soon surrounded by a delicate membrane, the same 
in character, though less thick and firm, with that which consti- 
tutes the walls of larger abscesses. The pus presents the usual 
appearance of this liquid, or it may be tinged by the presence of 
blood cells, or again it may be thick from partial absorption of the 
liquor puris so as to resemble softened tubercle. 

The abscess is ordinarily located in the centre of a collapsed 
lobule. In certain cases it approaches the surface of the lungs, so 
as to produce circumscribed pleurisy, with adhesion of the costal 
and visceral pleura. At the autopsy of such a case, on separating 
the adhesions and attempting insufflation, the air passes through 
the aperture, so that the lung on that side cannot be inflated unless 
the aperture is closed. Occasionally pneumothorax results from 
opening of the abscess into the pleural cavity. 

Dilatation of the bronchial tubes is an occasional result of bron- 
chitis, especially when severe and protracted. Emphysema is a 
common lesion observed in young children, whether death has 
occurred from disease of the respiratory or some other system. It 
is observed most frequently in the upper lobes, and oftener in their 
anterior than posterior portions. If it is vesicular, the sacs of air 
are numerous and minute, but if interstitial, they are large and 
irregular. If they are upon or near the surface of the lung so as to 
distend the pleura, they may attain considerable size. I have seen 
them of the size of a filbert in infants under the age of one year. 
In exceptional cases there are many of these air bladders situated 
between the root of the lung and its anterior border, and percep- 
tibly augmenting its volume. Severe bronchitis attended by labored 
respiration and a large collection of muco-pus in the tubes, while 
it produces collapse of certain lobules, is recognized as a common 
cause of these emphysematous lesions. 

Symptoms. — It is evident, from the description which has been 
given of the anatomical characters of bronchitis, that its symptoms 
vary greatly in severity in different patients. It usually com- 
mences with more or less coryza. The symptoms are headache, 
flushed face, elevation of temperature, acceleration and fulness of 
pulse. In the mildest cases these symptoms are scarcely appreciable. 
31 



482 BRONCHITIS. 

The child is observed to sneeze and have some defluxion from the 
nostrils, and this is followed by an occasional mild, almost painless, 
congh, which declines in the course of a few days. The respira- 
tion and pulse are scarcely accelerated, and the appetite is but 
slightly impaired. There may be a little fretfulness, but the 
child is not confined to his bed or room, and usually amuses him- 
self with his playthings. Auscultation in these mild cases reveals 
coarse mucous rales in the larger bronchial tubes, while the smaller 
tubes are free from mucus. Sibilant and sonorous rales are also 
observed, especially in the commencement of the bronchitis, at 
which time the secretion of mucus is suppressed or scanty. The 
cough in the commencement is for the same reason dry. It be- 
comes looser by the second or third day, the sputum consisting of 
frothy mucus, with the admixture of pus and epithelial cells. The 
pus becomes more abundant as the disease continues. Expectora- 
tion does not usually occur till after the age of four or five years ; 
under this age the sputum is ordinarily swallowed. 

The mild form of bronchitis described above, that in which 
only the larger bronchial tubes are affected, is common at all 
periods of infancy and childhood, but a severer grade of the dis- 
ease is also of common occurrence, exclusive of those cases in 
which the minute branches of the bronchial-tree are affected. It 
has already been stated that there is a tendency in bronchial in- 
flammation to extend downwards, and symptoms are proportionate 
in gravity to the degree of this extension. In severe bronchitis 
the pulse rises to 120 or 130 per minute, and the respiration is in 
a corresponding degree accelerated. The cough is frequent and 
painful, the pain being referred to the sternum, and often there is 
a steady dull pain in this region. The face is flushed and indica- 
tive of suffering, the temperature is considerably elevated^ and 
the appetite is greatly impaired or lost. There is frequently an 
exacerbation of symptoms in the latter part of the day. Depres- 
sion of the infra-mammary region during inspiration, and dilatation 
of the alse nasi, accompany grave attacks of the inflammation. 

Auscultation in severe bronchitis reveals the presence of rales 
in all parts of the chest, sibilant and sonorous sparingly, coarse 
mucous and sub-crepitant more abundantly. 

Capillary bronchitis or suffocative catarrh, the most dangerous 
form of this inflammation, is less frequent than bronchitis, which 
is limited to the larger tubes, or to the larger tubes and those of 
medium size. It may commence quite abruptly, but ordinarily 
it results from the milder form of the disease. The symptoms at 



SYMPTOMS. 483 

first are such as occur in the common form of bronchial inflamma- 
tion, but instead of abating or remaining stationary, they gradu- 
ally increase in severity till, suddenly, marked dyspnoea super- 
venes. The inflammation has now reached the minute tubes, and 
what promised to be an ordinary attack of bronchitis becomes one 
of great severity and danger. 

The respiration in capillary bronchitis is short and hurried. 
Sixty to eighty inspirations per minute are not infrequent, while 
the pulse also is greatly accelerated, attaining as high a number as 
140 to 160 or 180 beats per minute. The cough is frequent, and 
the sputum, which collects in abundance, is expectorated with 
difficulty. If expectorated so as to be examined, it is found to 
consist largely of frothy mucus with epithelial cells. After a few 
days, if the patient live, it becomes more purulent. Sometimes, 
as in bronchitis of the adult, streaks of blood appear upon the 
mucus. In the first days of capillary bronchitis, the temperature 
is considerably elevated, the face flushed and indicative of suffer- 
ing. The patient is restless, moving from one part of the bed to 
another, seeking in vain for relief. The digestive function is 
impaired, as in all severe inflammations ; the tongue is moist and 
covered with a light fur; the appetite is nearly or quite lost. The 
nursing infant nurses with difficulty, frequently relinquishing the 
breast on account of the dyspnoea ; older children take no solid 
food in consequence of the anorexia and the dyspnoea, and even 
drinks are swallowed hastily and apparently without relish, since 
deglutition interferes with respiration. On auscultation in capillary 
bronchitis, at first sibilant, and after a day or two sub-crepitant, 
rales are observed in every part of the chest. Percussion elicits a 
good resonance, unless the substance of the lung has become 
involved. As the disease approaches a fatal termination, the pulse 
becomes greatly accelerated, the respiration is also in a corres- 
ponding degree frequent and panting, the inspiration being accom- 
panied by marked infra-mammary depression and dilatation of the 
alee nasi. The face becomes pallid, the prolabia livid, and the tips 
of the fingers livid and cool. The mucus and pus, accumulating in 
the air passages, increase more and more the obstruction to the en- 
trance of air, and, finally, death occurs from apncea. The nursing 
infant usually ceases to nurse for several hours before death, and a 
state of stupor commonly precedes the fatal event, in consequence 
of the carbonaceous state of the blood. In young infants, espe- 
cially those under the age of six months, not only in capillary 
bronchitis, but in severe ordinary bronchitis, I have often observed 



484: BRONCHITIS. 

toward the close of life, intermissions in the respiration. It occurs 
after every six or eight or ten respirations, and equals in duration 
the time occupied in, perhaps, half a dozen respiratory movements. 
It is, therefore, an unfavorable prognostic, but some recover by 
stimulation in whom it occurs. 

The duration of acute bronchitis varies according to the extent 
of the inflammation. In the mildest form, the patient is con- 
valescent after three or four days, and, in severer forms that 
terminate favorably, the disease begins, ordinarily, to decline by 
the close of the first week or in the second. The progress of 
bronchitis is somewhat more rapid in young children than in those 
of a more advanced age. When convalescence is fully established, 
it is not unusual for the cough to continue three or four weeks, 
though gradually declining. It is loose and painless, and is 
scarcely regarded by the patient. 

Death sometimes occurs as early as the second or third day in 
capillary bronchitis. The younger the infant, with the same 
extent and intensity of inflammation, of course the sooner the fatal 
result. The ordinary duration of fatal bronchitis is from six to 
eight days. If the patient pass beyond the tenth day, decline of 
the inflammation may be confidently expected, and recovery, unless 
there is a complication. 

Occasionally bronchitis becomes chronic, lasting several months 
before it entirely ceases. The chronic form may result from mild, 
as well as severe, bronchitis. The active fever and accelerated 
respiration which characterize the acute affection abate, and the 
general health is nearly or quite restored ; but an occasional cough 
continues, and the respiration is often audible, from the mucus 
which collects in the tubes, or from thickening of the mucous 
membrane. Sometimes there is moderate febrile movement, espe- 
cially in the latter part of the day. On auscultation, coarse 
mucous, with perhaps sibilant and sonorous, rales are observed in 
the chest. 

There is great liability in chronic bronchitis to exacerbations. 
The disease often seems to be abating, and there is prospect of its 
speedy cure, when all the symptoms are intensified. The exacerba- 
tions are due to the fact that the bronchial surface, when it has 
been a considerable time inflamed, is very sensitive to the im- 
pression of cold. Even when the disease is entirely relieved, it 
is very apt to return by exposure to currents of air or changes of 
temperature. Chronic bronchitis occurs most frequently in the 
winter and in the spring and fall, when the weather is changeable, 



DIAGNOSIS — PROGNOSIS. 485 

and is most intractable in these periods of the year. Many cases of 
chronic bronchitis are associated with dilatation of the bronchial 
tubes or with emphysema. The general health in chronic bron- 
chitis, when not dependent on a tubercular deposit, ordinarily 
remains good. Tubercular bronchitis, which is the result of a 
grave disease, does not require a separate consideration. It is 
attended with emaciation, and is obstinate on account of the 
nature of the primary affection. It is due to the irritating effect 
of tubercular matter lying against the bronchial tubes. 

Diagnosis. — Bronchitis can ordinarily be diagnosticated by the 
character of the respiration and cough. The absence of hoarseness, 
stridulous inspiration, and croupy cough, excludes laryngitis ; and 
the absence of the expiratory moan and of the stitch-like pain on 
coughing, which characterize pneumonia and pleurisy, excludes 
those diseases. Accurate diagnosis, however, can be most readily 
made by percussion and auscultation. Examination of the chest 
enables us to state with positiveness, not only the nature, but the 
extent of the affection. If the inflammation is confined to the 
larger bronchial tubes, coarse rales are discovered in them, while 
finer mucous rales are absent. If the bronchitis is capillary, sub- 
crepitant rales are discovered in the smaller tubes. Percussion gives 
clear resonance on both sides, except in those instances in which 
collapse or pneumonia has supervened. 

Prognosis. — Bronchitis, limited to the larger bronchial tubes, 
or to these and those of medium size, terminates favorably in a 
large majority of cases. Occasionally, severe inflammation, not 
extending to the smaller tubes, proves fatal in young infants, or 
those of feeble constitution. True capillary bronchitis is, on the 
other hand, a disease of great danger. It may be fatal at any 
period of childhood, but the younger the patients and more feeble, 
the greater the proportion of deaths. Under the age of one year, 
it is one of the most fatal diseases of early life. 

The prognosis, in the commencement of all cases of bronchitis 
of average severity in the young child, should be guarded, on 
account of the tendency of the inflammation to extend, since 
ordinary bronchitis may become capillary. After five or six days, 
extension ceases, and, if during that time there is no increase in 
the severity of symptoms, the prognosis is favorable. Signs which 
indicate an unfavorable result are increasing frequency of pulse 
and respiration, difficult and scanty expectoration, restlessness, a 
countenance indicative of suffering, and a progressively greater 
accumulation of mucus in the bronchial tubes, as determined by 



486 BRONCHITIS. 

auscultation. Pallor and coldness of the face and extremities, 
lividity of the tips of the fingers, rapid and feeble pulse, drowsi- 
ness, diminution of cough, while the mucus and pus accumulate in 
the bronchial tubes, and, in young children, intermissions in the 
respiration, indicate the near approach of death. Cases may, how- 
ever, recover by proper treatment, although the symptoms are 
most unfavorable. 

It is unnecessary to mention the favorable prognostic signs of 
bronchitis. This disease, when fully established, continues a cer- 
tain number of days, whatever remedial measures are employed, 
and if the symptoms do not increase in severity during the first five 
or six days, a favorable result is highly probable. The prognosis 
in chronic bronchitis is ordinarily favorable, so far as life is con- 
cerned, provided there is no emaciation. If there is emaciation, 
the bronchial inflammation may be due to tubercles in the bronchial 
glands or lungs, and, of course, the prognosis is unfavorable. 

Treatment. — Bronchitis may be rendered much milder, and 
perhaps even prevented, by an emetic employed in the first twelve 
or twenty-four hours, in conjunction with a warm bath. The 
physician is not, however, ordinarily called sufficiently early to 
render this treatment effectual. The remedial measures proper for 
this disease vary greatly, according to the stage and intensity or 
extent of the inflammation and the age of the patient. Bronchitis, 
limited to the larger tubes, requires simple measures. A laxative 
may be employed, with a mild expectorant, and moderate counter- 
irritation should be produced by camphorated oil, or the occasional 
employment of a sinapism. I have sometimes ordered for these 
cases a mixture recommended by Dr. James Jackson, of Boston, 
in his letters to a young physician. " For young children," .... 
says he, "I employ the following: Take of either almond or olive 
oil, of syrup of squills, of any agreeable syrup, and of mucilage of 
gum acacia, equal parts, and mix them. Of this mixture, a tea- 
spoonful may be given to a child at two years of age ; a little less 
if younger, and increased if older, so as to double the dose to one 
in the sixth year. This may be given from three to six times in 
the twenty-four hours. Sometimes a little opiate must be added 
at night to appease an urgent cough." These cases also do well 
with simple mucilaginous drinks in conjunction with gentle ape- 
rients. 

Bronchitis, extending beyond the primary or secondary bronchial 
divisions, requires more careful watching and more decided mea- 
sures. The abstraction of blood by leeches, or otherwise, is seldom 



TREATMENT. 487 

required in the treatment of bronchitis. Occasionally, it the in- 
flammation is intense and the symptoms urgent, moderate abstrac- 
tion of blood at an early period may be useful, but the employment 
of cardiac sedatives under such circumstances is generally prefer- 
able. 

As a rule, actively depressing agents should be avoided in the 
treatment of bronchitis in patients under the age of two years ; 
and, on the other hand, sustaining remedies are in a large propor- 
tion of cases required after the first two or three days. Many 
infants with bronchitis are sacrificed in consequence of the old 
theory, which still influences medical practice, that an inflamma- 
tion, with its increased force of circulation, is necessarily best 
controlled by depletory and sedative measures. Remedies too de- 
pressing are prescribed, and with a less favorable result than 
would follow a strictly expectant course of treatment. 

What is, therefore, the proper mode of treating bronchitis, 
severe or of ordinary gravity, occurring in infancy and childhood ? 
It is supposed that the physician is called when the inflammation 
is fully established, or that, if he has seen the patient at the com- 
mencement, and has prescribed an emetic, it has failed to throw 
off the disease. A large emollient poultice, not thicker than the 
cover of a book, so wet as to produce constant moisture of the 
surface, and sufficiently irritating to produce constant redness 
without necessitating its removal, should be applied to the front 
and sides of the chest, and over it an oil-silk jacket placed. I pre- 
fer a poultice of the following: — 

R. Pulv. sinapis §ss ; 

Pulv. semin, lini ^viij. Misce. 

Local treatment in bronchitis is very important. The exact 
mode of applying it, or the substances used, matters little, provided 
it meets the indication, which is twofold — namely, derivation to 
the surface, and the application to it of warmth and moisture. 
Such applications are found, by experience, to give most relief. 
"Warmth and moisture are furnished by cataplasms most con- 
veniently, or by warm water applications under oil-silk. 

Derivation to the surface, early made' and repeated, tends to 
check the downward extension of bronchitis ; but it is not advisable 
to vesicate, or to produce anything more than moderate and con- 
tinued redness. Often improvement in symptoms is observed, 
especially less dyspnoea and restlessness, immediately on the em- 
ployment of the local measures recommended above. 



488 BRONCHITIS. 

The general or internal treatment appropriate for bronchitis 
varies according to the age and the character of the inflammation, 
whether primary or secondary. The following formula will be 
found useful for infants affected with primary bronchitis : — ■ 

R. Spts. aether nitr. ^j ; 
Syr. ipecacuanhas, 
01. ricini, aa 3ij ; 
Syr. bal. tolut. 3vij. Misce. 
One teaspoonful for an infant one year old every two to four hours. 

Another eligible formula is the following : — 

R. Syr. ipecacuanhas 31J ; 
Potas. acetat. gr. xvj-gss ; 
Aq. anisi 3 x iv. Misce. 
Dose, one teaspoonful for an infant of six months. 

If there is decided febrile reaction, tincture of digitalis, one or 
two drops, according to the age, may be added to each teaspoonful. 

In a majority of cases of infantile bronchitis, this mode of treat- 
ment is appropriate only for the first few days, after which, if 
farther medication is required, more sustaining, or even stimulating, 
medicines are proper. 

For children over the age of three years, if the previous health 
has been good, and the bronchitis is primary, aconite or veratrum 
viride is often useful in the first stage of the inflammation. The 
following is a recipe for a child of five years : — 

R. Tinct. rad. aconit. gtt. xij ; 
Syr. scillas comp. 5ij ; 
Syr. bal. tolut. 3xiv. Misce. 
One teaspoonful every two to four hours ; the medicine to be omitted, or given 
at a longer interval, if the frequency of the pulse is reduced. 

The tincture of veratrum viride is more powerful than that 
of aconite, and may be employed in the same dose for those who 
are more robust. 

The effect of cardiac sedatives should be carefully watched. In 
general they should be administered only during the first three to 
five days ; but if the child is robust, with full and strong pulse, 
they may be continued longer. As the active inflammation begins 
to abate, simple expectorant mixtures may be given, as syrup of 
squills, or ipecacuanha in spiritus Mindereri. At this stage of 
bronchitis, it is often best to commence the use of stimulating ex- 
pectorants, and they are required in nearly all cases of advanced 
bronchitis. In secondary forms of the disease, as when it occurs 
in connection with hooping-cough or measles, such expectorants 



TBEATMENT. 489 

should be employed from the first ; and also if there is a state of 
feebleness or cachexia, although the bronchitis is primary. It is 
important for successful practice to be able to determine at what 
period in the disease this class of medicinal agents should be pre- 
scribed. In doubtful cases, it is safer to prescribe them than those 
of a depressing character ; but it is better to employ, for a day or 
two, a simple mucilaginous or other soothing mixture, after which 
a stimulating expectorant can be given. A favorite prescription 
with me is the following : — 

R. Ammon. carbonat. gr. xvj-xxiv ; 
Tinct. sanguinar. gtt. xxiv ; 
Syr. senegse gij ; 
Ext. glycyr. 5ss ; 
Aquae 5 x iv. Misce. 
Dose, one teaspoonful every two or three hours to a child of two years. 

If there is restlessness, Dover's powder, paregoric, or syrup ot 
poppies should be given with this mixture, or separately. 

As convalescence approaches, the medicine should be administered 
less and less frequently or in smaller doses. Emetics in ordinary 
cases of bronchitis are not required, except in the commencement. 
In severe bronchitis, however, especially when the smaller tubes 
are inflamed, they are sometimes of great service. The cases which 
require their administration are those in which mucus and pus 
collect in the tubes more rapidly than they are expectorated, so as 
to give rise to urgent dyspnoea. Nothing gives such decided and 
immediate relief under these circumstances as an emetic. The 
object to be gained is obviously very different from that in the 
commencement of bronchitis, and such agents should be employed 
as act promptly, with the least possible depression. Sulphate of 
zinc or of copper is, therefore, an appropriate medicine. The former 
may be given in a dose of Rve grains ; the latter, of one or two 
grains to a child -&.ve years old. If there is considerable strength 
of pulse and heat and dryness of surface, ipecacuanha may be 
administered. If there are evidences of exhaustion, stimulants 
may be administered immediately before and after emesis. Infants 
oppressed by the accumulation of mucus and pus may sometimes 
be relieved by tickling the fauces with the finger. This provokes 
vomiting, and the viscid mucus which collects at the entrance of 
the glottis is removed by the finger. 

In secondary bronchitis whatever the age, in primary or second- 
ary occurring in infants or feeble children, the diet should, as a 
rule, be nutritious through the entire disease. Eobust patients, 



490 PNEUMONITIS. 

or those who have had ordinary health, if over the age of two 
years and affected with primary bronchitis, should have light diet, 
chiefly farinaceous in the first days of the attack, after which 
animal broths are proper. Whatever food is given in severe bron- 
chitis must be in the form of drinks, since the appetite is lost, 
while the thirst is such that liquids are less likely to be refused. 

In primary bronchitis, if mild or of ordinary severity, alcoholic 
stimulants are not required. In secondary bronchitis they are 
often needed, and also in capillary or severe ordinary bronchitis 
if there is dyspnoea with evidences of prostration. The occasional 
loose cough which is often present during the period of conva- 
lescence requires but little treatment; either no medicine or a 
gently stimulating expectorant may be given. 



CHAPTER V. 

PNEUMONITIS. 



In children over the age of five or six years, pneumonitis differs 
but little in form or phenomena from that of the adult, being 
ordinarily primary except as it depends on an irritant, as tubercles, 
and extending rapidly over one or more entire lobes. In those 
under the age of iive years it is, on the other hand, as a rule, a 
secondary affection, and limited to a part of a lobe. Most writers, 
until recently, have classified cases according to their origin as 
primary and secondary, or their extent as lobar and lobular, or 
their duration as acute or chronic. A better classification, having 
an anatomical basis, is that into catarrhal, croupous, and inter- 
stitial. 

Catarrhal pneumonitis consists in an inflammation of the air- 
cells, with an abundant proliferation of epithelial cells within them, 
and the exudation of serum but not of fibrin. The secondary and 
lobular pneumonitis of young children, alluded to above, is usually 
of this character. Croupous pneumonitis consists also in an inflam- 
mation of the alveoli, but with an abundant formation of pus-cells 
within them, and the exudation of fibrin and serum. The lobar 
and primary pneumonitis of advanced children and adults is com- 
monly of this character. In both catarrhal and croupous pneumo- 
nitis, therefore, the solidification of the lung and exclusion of air are 



CAUSES. 491 

due mainly to the newly-formed cellular elements with which the 
alveoli are filled, though the source and nature of these cells differ 
in the two diseases. Interstitial pneumonitis consists in an in- 
flammation and hyperplasia of the connective tissue of the lungs. 
It is the chronic pneumonia of authors, resembling in many respects, 
in its anatomical and clinical characters, cirrhosis of the liver. 
The inflammation which produces this result is subacute, and in 
nearly all cases is dependent on some persistent local disease in the 
minute bronchial tubes or lungs, as softened or cheesy tubercles, 
cancer, abscesses, protracted inflammation of the alveoli or bron- 
chioles, whether produced by the inhalation of dust of an irritating 
nature or other cause. Interstitial pneumonia is much more rare 
in children than adults, and, as it presents no peculiar features in 
them, it need only be alluded to in this connection. 

Causes. — Croupous pneumonitis in most cases results from that 
common cause of inflammatious — namely, taking cold. It com- 
mences as a primary disease within a few hours after exposure. 
Catarrhal pneumonitis, in exceptional instances, also commences 
abruptly as a primary disease from the same cause, but being, 
probably in nine cases out of ten, secondary, it commonly results 
from antecedent pathological states, which we will enumerate. 

First. Many cases result from bronchitis. The inflammation 
extending downward engages the minute bronchial tubes, and 
from them traverses the alveoli of one or more lobules. This is 
the broncho-pneumonia of children described by authors ; it occurs 
most frequently between the ages of six and eighteen months. 

Secondly. Hypostasis, or passive congestion, is an important 
factor in the causation of many cases, and in feeble infants it is 
not infrequently the sole cause. Infants with feeble health and 
languid circulation, lying in their cribs day after day with little 
movement of the body, are very liable to passive congestion of the 
depending portions of their lungs, and this by and by eventuates 
in a cell proliferation within the alveoli — in other words, a pneumo- 
nia presenting some peculiarities, but of the catarrhal form. In 
foundling hospitals, where feeble infants are received and treated, 
this is one of the most frequent pathological states, and is the pre" 
vailing form of pulmonary inflammation. It is sometimes de- 
scribed as hypostatic pneumonia. Hence physicians, whose obser- 
vations have been largely in such institutions, have almost ignored 
any other form of pneumonia in infants. Billard, a close and 
accurate observer, wrote nearly half a centuiw ago: "Pneumonia 
of infancy presents peculiar characters, in which it differs from the 



492 PNEUMONITIS. 

same affection in adults. Instead of being an idiopathic affection 
arising from irritation developed in the pulmonary tissue under 
the influence of atmospheric causes, which often excite the disease, 
the pneumonia of young infants is evidently the result of a stagna- 
tion of blood in their lungs. Under these circumstances this 
blood may be regarded as a kind of foreign body .... It would, 
therefore, appear that inflammation of the lungs, which produces 
hepatization, arises in infants, in general, from some mechanical or 
physical cause." Valleix also states that he found the lesions of 
pneumonia in a majority of the infants who died in the Hopital 
des Enfants Trouves. The statements of Valleix are applicable also 
to the Infants' Hospital, and Nursery and Child's Hospital, of this 
city, as regards those cases in which death results from chronic 
disease. We shall see hereafter that hypostatic pneumonia is one 
of the most common complications of chronic infantile entero- 
colitis, the summer complaint of the cities. 

Thirdly. Catarrhal pneumonia of infants sometimes results from 
collapse. It is not unusual to find, at the autopsies of infants who 
have died in a state of emaciation and feebleness, portions of the 
lungs remote from the bronchi collapsed, as, for example, the thin 
edges of the inferior lobes, and the tongue-like process of the left 
upper lobe, the process which lies over the heart. The immediate 
cause of the collapse has been a bronchitis, or it has resulted di- 
rectly from the general weakness of the infant, and its feeble res- 
pirations. Now, a collapsed lung soon becomes affected by passive 
congestion. The functional activity of an organ favors circulation 
through it, and if the function is abolished the flow of blood in 
the part is retarded, and stasis more or less complete results. The 
hyperaemic state of collapsed pulmonary lobules presents the same 
anatomical condition for the supervention of pneumonia, as occurs 
in cases of hypostatic congestion. Consequently, cell proliferation 
soon begins in the collapsed alveoli, the volume of the affected 
lung increases, and it becomes firmer and more resisting to the 
touch, and the microscope reveals the characters of a subacute but 
genuine catarrhal pneumonitis. I have made or have procured 
microscopic examinations of a considerable number of such speci- 
mens, and have found the alveoli more or less filled with cells of 
the epithelial character. 

In rare instances in infancy and childhood pneumonitis results, 
as it more frequently does in the adult, from an embolus detached 
from a clot, which had formed in some remote vein, in consequence 
of arrest of circulation in it, by inflammation of the contiguous 



ANATOMICAL CHAKACTEKS. 493 

tissues. This is described by writers as a distinct form of pneumo- 
nitis designated embolic or embolismal. A specimen showing this 
mode of causation was exhibited by me at the New York Patho- 
logical Society, in February, 1868. An infant born January 22d, 
1868, of strumous parents, had been fretful, but without appreciable 
ailment till February 3d, when inflammation of the connective 
tissue occurred on the anterior aspect of the left leg, a little below 
the knee. This extended downwards, suppurated, and the pus 
was evacuated February 5th. In the mean time, three other similar 
inflammations occurred, two on the right foot and leg, and the 
other over the parietes of the chest in the right infra-mammary 
region. Suppuration occurred in all of these. 

On February 8th this infant was suddenly seized with extreme 
dyspnoea, and died in a few hours. Numerous minute puriform 
collections (formerly called metastatic abscesses) were discovered 
in each lung, most of them scarcely 
larger than a pin's head. One of them 
on the right side in the middle lobe 
connecting with a bronchial tube had 
ruptured into the pleural cavity, caus- 
ing pneumothorax, collapse, and incipi- 
ent pleuritis. 

The annexed figure exhibits the 
microscopic appearance of this softened 
fibrin, which, to the naked eye, so 
closely resembled pus. 

On account of the speedy death, the emboli had produced, in the 
lobules where they had lodged, little more than congestion or the 
first stage of pneumonitis around them. Had the infant lived 
longer, doubtless the ferments or the vibriones, which some con- 
sider the irritating element of emboli, would have produced sup- 
purative inflammation. 

Anatomical Characters. — Nothing need be added in this con- 
nection to what has already been said, in reference to interstitial 
and embolismal pneumonias. Being comparatively rare in children, 
they present the same anatomical characters as in the adult. That 
unimportant form of pneumonia called pleurogenous, and which 
consists in a croupous inflammation of the superficial infundibula of 
the lung underneath an inflamed pleura, occurs in children as well 
as adults. Being secondary to the pleuritis produced by extension 
of the inflammation of the pleura, it gives rise to no physical signs, 
or appreciable symptoms, on account of its slight extent, and as it 
presents no peculiar features in the child, it need only be alluded to. 




494 PNEUMONITIS. 

Croupous pneumonitis, which we have stated is the ordinary form 
of pulmonary inflammation in children over the age of five years, has 
the same anatomical characters as in the adult. It ordinarily in- 
volves an entire lobe. It is more frequent in the right than left 
lung, and in whichever lung it occurs its most frequent seat is 
the lower lobe. The inflammation may, however, be limited to an 
upper lobe, especially on the right side. It ordinarily commences 
near the root of the lung and extends forward. 

Croupous pneumonitis presents three stages, that of congestion, 
red hepatization, and gray hepatization. In the stage of conges- 
tion the capillaries in the walls of the alveoli are greatly distended, 
bulging forward in loops within the alveolar spaces so as to diminish 
them, and a viscid albuminous fluid begins to exude, in which 
points of extravasated blood appear. The affected lung in this 
stage has a deep red color, its elasticity is greatly diminished, and 
its density and weight increased. On account of the reduced size 
of the alveoli from the bulging of the alveolar walls, and the 
viscid fluid within the alveoli and terminal bronchial tubes, the 
function of the affected lobe is nearly lost, and hence the dyspnoea 
which patients experience in the first stage of the inflammation. 

The second stage is characterized by the continued and increased 
escape of the liquor sanguinis, and red and white corpuscles, 
through the stigmata or little apertures which exist normally in 
the walls of the capillaries. The inflamed alveoli, and the minute 
bronchial tubes which terminate in them, are filled with this 
pneumonic exudation. The relative proportion of the elements 
of the blood in the exudate varies in different cases. Fibrin 
is always present, immediately coagulating in delicate filaments 
within the interstices of which the corpuscles are lodged. The 
white corpuscles in some cases are much in excess of the red, while 
in others the red predominate. The lung in the second stage con- 
tains no air, has a greater specific gravity than water, is friable so 
as to be readily torn and penetrated by the finger. The torn 
surface in the adult presents a granular appearance, each granule 
being the contents of an air-cell. In the child the granules are 
not distinct on account of the small size of the air-cells, but the 
volume of the inflamed lobe is somewhat increased as in the adult. 

The stage of gray hepatization succeeds, in which the volume 
of the lung is still greater. The change of color is due partly to 
the compression of the capillaries by the inflammatory material, 
partly to the destruction of the red corpuscles, and disappearance to 
a greater or less extent of their coloring matter, while the white 



ANATOMICAL CHARACTERS. 495 

corpuscles (pus-cells) remain, but more to commencing fatty degene- 
ration in the exudate prior to its liquefaction. In favorable cases 
the lung soon returns to its normal state, the liquefied substance 
which filled the alveoli being in part absorbed, in part expectorated. 

Croupous pneumonitis often causes inflammation of the portion 
of the pleura which covers it. Pleuritis developed in this way is 
circumscribed, but it frequently extends beyond the inflamed 
parenchyma to the distance of one or two inches. Bronchitis is 
also a common accompaniment. It may be general, in which case 
it occurs independently, or be limited to the tubes lying within 
the inflamed lung, in which case it results like the pleuritis from 
the pneumonitis. It is seen from this description that the pus-cells 
which are produced so abundantly in the alveoli are believed to be 
chiefly exuded white corpuscles of the blood. Possibly some of 
them may be produced by proliferation of the epithelial cells, 
which line the alveoli, in the same manner as they are believed 
to be produced in the bronchial tubes. 

Catarrhal pneumonitis, which is, as we have stated, for the most 
part the lobular pneumonitis of writers, and which, with an occa- 
sional exception, is the form of inflammation in children under the 
age of five years, presents not only clinical but anatomical features, 
which distinguish it from the croupous form of the disease. Those 
who have witnessed few post-mortem examinations of young 
children, and whose views of the lesion are influenced by the ex- 
pression lobular, are apt to suppose that there is an alternation of 
inflamed and healthy lobules, so that the surface of the lung pre- 
sents an appearance not unlike mosaic work. This is a mistake. 
Although an entire lobe is seldom inflamed as in croupous pneu- 
monitis, the inflammation commonly extends over more or fewer 
contiguous lobules, but we find certain lobules in the midst of the 
inflamed area, which are but slightly affected or have escaped 
entirely. The extent of the inflammation is ordinarily from one 
to three inches, but I have seen a nodule of true catarrhal pneu- 
monia not larger than a pea, while every other portion of the lung 
was healthy. On the other hand, almost an entire lobe may appear 
hepatized to the naked eye as in the croupous inflammation, but 
by a careful examination certain lobules will be found unaffected. 
Thus, in a case in the Nursery and Child's Hospital, in which 
death occurred at the age of one year from pneumonitis supervening 
upon pertussis, an entire lower lobe, with the exception of a little 
of its anterior border, presented the appearance and feel of red hepa- 
tization, but a careful microscopic examination revealed not only 



496 PNEUMONITIS. 

the absence of fibrin in the exudate, showing the catarrhal nature 
of the inflammation, but also certain lobules in the midst of the 
inflamed lung which were not involved. 

The first change occurring in a lung invaded by catarrhal 
pneumonitis is congestion, whether active, as in the common form 
of the disease, in which the inflammation has extended into the 
lung from the bronchioles, or passive, as when the inflammation 
results from hypostasis or collapse. An exudation of serum, but 
not of fibrin, follows, and soon the epithelial layer which lines the 
alveoli begins to swell. The nuclei of the epithelial cells divide, 
the cells themselves forming large round cells with vesicular 
nuclei. These cells, to which the solidification of the lung is 
mainly due, are, therefore, on account of their origin and appear- 
ance, regarded as epithelial. The alveoli in catarrhal pneumonitis, 
it is seen, are filled with an inflammatory product quite different 
from that in the croupous inflammation. 

Inflammation of the pleura over the inflamed lung, so common 
in croupous pneumonia, and which gives it the name pleuro- 
pneumonia, by which it is sometimes designated, rarely occurs in 
this disease. The seat of this inflammation is ordinarily the 
posterior part of the lungs, even when it results from extension of 
the inflammation from the bronchial tubes. When resulting from 
collapse, it affects chiefly those lobules which are remote from the 
bronchi, and which the air enters only by a long circuit. 

Catarrhal pneumonitis, when it arises from extension of acute 
inflammation of the bronchioles, is acute, but in those forms of the 
disease which supervene upon passive congestion it is subacute. 
The alveoli are less distended by inflammatory products than in 
croupous pneumonia, not only from the absence of fibrin, but from 
a less amount of cells. Hence the volume of the inflamed lung is 
not so great as in that disease, and the torn surface, even in the 
adult, does not present a granular appearance. Hence, also, the 
stage of gray hepatization does not supervene so uniformly and 
regularly, since there is less compression of the capillaries in the 
alveolar walls, and the mutual pressure of the inflammatory pro- 
ducts is less. In infants who have died with this form of pneu- 
monitis, of six or eight weeks' duration, it is not unusual to find 
the affected lobules still in the stage of red hepatization. Cell 
proliferation occurs in the bronchioles of the inflamed lung as in 
the alveoli, producing within them numerous plugs, which, though 
they obstruct the entrance of air, are not so firm as in croupous 
pneumonitis, as they are destitute of fibrin. 



CHEESY PNEUMONITIS. 497 

In favorable cases the lung affected by catarrhal inflammation 
returns to its normal estate, probably by the same process as in 
croupous pneumonitis. In other cases, especially in scrofulous and 
feeble children, the inflammation instead of resolving passes into 
what is now designated cheesy, or by certain writers scrofulous, 
pneumonitis. 

Cheesy Pneumonitis. — Cheesy degeneration of the inflammatory 
product occasionally occurs in the croupous form of inflammation, 
but it is more common in the catarrhal. I have most frequently 
observed it in New York during epidemics of measles, when this 
form of pneumonitis supervened upon the. catarrhal bronchitis of 
that disease. Cheesy pneumonitis is in its nature chronic, and 
attended with great reduction of the vital powers. 

Cheesy degeneration of the exudate or infiltrate consists essen- 
tially in the absorption of the liquid portion, and fatty degenera- 
tion of the solid. The obstruction of the circulation in the 
capillaries and the accumulation of cells in the alveoli and bron- 
chioles which cannot be expectorated, are conditions which favor 
the cheesy metamorphosis. The appearance and consistence of the 
lung when it has undergone this change are well expressed by the 
term which is employed to designate it. The cheesy mass consists 
of fatty, shrivelled, and fragmentary cells, and amorphous matter, 
in which can be traced the elastic fibres and larger vessels of the 
parenchyma, the other histological elements having disappeared. 

The caseous mass after a time softens, attracting moisture from 
the surrounding tissues. The molecular detritus and the shrivelled 
cells are now suspended in a liquid, and, like any dead matter, they 
are irritants to the surrounding lung substance. The bronchial 
tube which supplies the diseased lobule, and which in many in- 
stances was the starting-point of the disease, again becomes per- 
vious, either by softening of the plug or by ulceration at a higher 
point upon its walls, and air is admitted, which promotes the 
putrefactive process and chemical changes of the caseous substance. 

The lesion now described is that of pulmonary consumption, a 
disease not infrequent in children of two or three years. There 
are as yet no tubercles, but the presence of softening caseous 
material in the lungs very frequently leads to their development 
(see Art. Tuberculosis), and accordingly, before the case ends, 
clusters of tubercles may appear in the connective tissue and walls 
of the vessels of the lungs and in other organs. 

In the subsequent progress of cheesy pneumonitis, if the patient 
live sufficiently long, there occurs more or less expectoration of 
32 



498 PNEUMONITIS. 

the offending substance, producing a cavity. Around the cavity 
a vascular pyogenic membrane forms, upon which granulations 
arise. These granulations, which produce pus abundantly, and 
from which small extravasations of blood are frequent, are gradu- 
ally transformed into connective tissue. If the dead portion is 
expectorated, and there is a single small cavity, the child may 
recover, the empty space being finally filled up by the extension of 
the granulations, and the production of a cicatrix, which contracts, 
producing a puckered appearance. Ordinarily, however, there are 
several depots of cheesy matter, and several cavities resulting, 
which continue to enlarge by the continued softening of cheesy 
matter in their walls. Often, also, certain of the cavities intercom- 
municate. The bronchial glands undergo hyperplasia, and certain 
of them are apt, also, to become cheesy. As the disease advances, 
the suppuration and expectoration increase. The fatal result 
occurs sooner in children than in adults, and, therefore, the lesions, 
destructive and inflammatory, observed at autopsies, are ordinarily 
not so far advanced in the former as in the latter. Other unfavor- 
able changes may occur in the hepatized lung, but cheesy degene- 
ration is the most common and noteworthy. 

Whether it is possible to inflate a lung which presents to the 
naked eye the appearance of pneumonitis, has long been regarded as 
a reliable sign of the presence or absence of inflammatory consoli- 
dation. The facts as regards the possibility of insufflation are 
these: In croupous pneumonitis, when it has passed beyond the first 
stage, insufflation is impossible in the lung of the child as well as 
adult, with the utmost force of the breath. We produce emphy- 
sema in healthy portions of the lungs, while the inflamed area is 
not encroached upon. 

On the other hand, in catarrhal pneumonitis, which we have seen 
is the common form of pulmonary inflammation in children under 
the age of five or six years, and in which there is less distension of 
the air cells by inflammatory products, the lung can be inflated, ex- 
cept in protracted cases, but when fully inflated the solidified lobules 
can still be felt between the thumb and fingers. In protracted 
catarrhal pneumonitis, as well as in protracted collapse, which, in- 
deed, may and often does become a pneumonitis, full inflation is 
impossible. Central portions still remain impervious to air. While, 
therefore, the possibility or impossibility of inflating a lung re- 
moved from an adult, and which presents to the naked eye the 
appearance of pneumonic solidification, is a valuable sign as in- 



SYMPTOMS. 499 

dicating whether or not the disease was pneumonitis, in the child 
little importance can be attached to it. 

Symptoms. — Croupous pneumonitis commonly begins abruptly, 
or it is preceded for a brief period by symptoms of a cold. In the 
adult, the abrupt commencement is ordinarily with a chill. In 
the child, there is often a sensation of chilliness, but a distinct 
chill is not common. Convulsions sometimes occur in place of a 
chill. Catarrhal pneumonitis, being ordinarily a secondary disease, 
begins in a more gradual way, its symptoms being preceded by, and 
associated with, those of the primary affection. 

The symptoms of acute pneumonitis, whether catarrhal or 
croupous, are the following : Anorexia, thirst, restlessness, elevation 
of temperature, acceleration of pulse according to the intensity of 
the inflammation and the feebleness of the patient, flushed face, a 
countenance indicative of suffering, accelerated respiration, with 
an expiratory moan. These symptoms are constant in the acute 
inflammation unless of the mildest form. Those which are im- 
portant I shall describe more fully. 

The expiratory moan is described by writers as a pathognomonic 
symptom of this disease, or of pleurisy. It is evidently due to the 
pain experienced by the friction of the inflamed pleura. As a rule, 
the expiratory moan does indicate either pneumonitis or simple 
pleuritis ; but there are exceptions. It may occur, for example, 
from indigestible substances in the stomach and intestines, giving 
rise to acute dyspepsia ; or from certain forms of abdominal inflam- 
mation, which render movements of the diaphragm painful. 

The cough in the first days of pneumonitis is often dry or hacking 
and painful. It afterwards, if the case is favorable, becomes looser, 
and is painless. "We very seldom observe in the child the bloody 
sputum which characterizes pneumonitis in the adult, since in 
catarrhal inflammation there is little or no exudation of blood 
corpuscles. The sputum, which in this form of the disease is the 
product of secretion and cell proliferation, is at first thin and frothy, 
but afterwards thicker and less tenacious from the greater number 
of cells. There is often, in the first period of the inflammation, 
pretty severe and constant headache, the patient complaining of 
the head, if old enough to speak, before he does of the chest. In 
a severe attack the child at this period lies with the eyes shut, ap- 
parently in a half-cOnscious state, fretful if spoken to or aroused, 
so that the physician might be led to suspect the presence of cere- 
bral disease. If there is vomiting, accompanied with sudden 
twitching of the muscles, and convulsions — symptoms which some- 



500 PNEUMONITIS. 

times occur — the liability to error in diagnosis is greatly increased. 
Cerebral symptoms are more prominent in the commencement of 
pneumonitis than subsequently. As the disease advances they 
subside, and symptoms referable to the chest become more con- 
spicuous. 

The breathing is, as I have said, accelerated. Thirty or forty 
respirations per minute are common, and, in severe cases, the num- 
ber reaches sixty or even eighty. In infants there is greater fre- 
quency of respiration than in children. In those at the breast, if 
the dyspnoea is urgent, nutrition is sometimes seriously interfered 
with, since in these severe cases respiration is performed more 
through the mouth than nostrils, so that if the infant seizes the 
nipple, it is forced to relinquish it in order to breathe. Dilatation 
of the alse nasi, and depression of the infra-mammary region, accom- 
pany inspiration. The dyspnoea in catarrhal pneumonitis is often 
due in great part to accompanying bronchitis. 

The temperature in mild cases of pneumonitis is elevated to 
about 101° to 103° ; in severe cases it may reach 105° or even 107°, 
the former being the highest observed by Mr. Squire. In ninety- 
seven observations made by M. Roger, the average temperature 
was 104° during the active period of the inflammation. The face 
is therefore flushed, and the heat of surface pungent, except in 
weakly children, in whom, even in severe and active inflammation, 
the face is sometimes pale, and the extremities of natural or less 
than natural temperature. 

The tongue is moist, and covered with a light fur ; the thirst is 
such that nutriment may be given in the form of drinks, when the 
loss of appetite prevents the use of solid food. The bowels are 
usually constipated. The secretions, in the first and second stages, 
are diminished. The urine is more deeply colored than in health, 
and in vigorous patients it deposits urates on cooling. The chlo- 
rides are also deficient, or absent from the urine, as long as the 
inflammation is extending. 

In favorable cases, in from seven to ten days the heat and thirst 
decline ; the pulse and respiration gradually become less frequent ; 
the cough looser ; the features have a more placid or contented 
expression ; the appetite returns, and the patient is again amused 
by playthings. The improvement is progressive, but gradual. A 
slight cough is occasionally observed for two or three weeks after 
convalescence is fully established. 

Death in the acute stage of the inflammation commonly occurs 
from asthenia. The pulse gradually becomes more frequent and 



PHYSICAL SIGNS. 501 

feeble, the respiration more oppressed, and finally, as death ap- 
proaches, the face and extremities become cool. Occasionally death 
results from apncea, due in great part to coexisting bronchitis. In 
exceptional instances it occurs from convulsions, followed by coma, 
especially in the first week. Death, in those protracted cases in 
which the inflammatory products have undergone cheesy degene- 
ration, is usually from asthenia. 

Such are the symptoms and progress of ordinary acute pneumo- 
nitis in children. "When the inflammation is subacute, as in those 
forms of the disease which result from collapse or hypostasis, the 
symptoms are less pronounced. The respiration in such cases is 
but moderately accelerated, is attended by little pain, and therefore 
the expiratory moan is often absent. An occasional short, dry 
cough occurs, with so little increase of temperature and quicken- 
ing of the pulse that the pneumonitis is apt to be overlooked by 
the physician, the symptoms being referred to bronchitis. Pleuri- 
tis does not occur in connection with this form of pneumonitis, ex- 
cept when a small abscess or gangrene occurs in an affected lobule 
directly under the pleura. A few such cases I have observed. 

Tubercular pneumonitis extends over much or little of the lung 
according to the amount of tubercles. The symptoms are like 
those of severe primary pneumonitis, superadded to such as pertain 
to tuberculosis. This inflammation, when once established in the 
consumptive child, commonly continues till the close of life. I 
have sometimes had these cases under observation for several 
consecutive weeks, even months, and during the whole time there 
was not only acceleration of pulse and respiration, but the expira- 
tory moan. As regards pneumonitis occurring in hooping-cough, 
it is an interesting fact that its symptoms modify those of the 
primary disease, so that, during the active period of the inflamma- 
tion, the paroxysmal cough diminishes, and a short, hacking cough 
and expiratory moan occur in place. As the inflammation abates, 
the spasmodic cough returns. Pneumonitis, occurring in measles, 
is more obstinate, protracted, and dangerous than the primary 
form. It usually commences about the period of the decline of 
the eruption, and, in favorable cases, continues two or three weeks. 
It is then a sequel, rather than complication. 

Physical Signs. — -The physical signs of pneumonitis in infancy 
and childhood are the same as in the adult, but in a large propor- 
tion of cases they are less distinct. In a majority of patients 
under the age of three years the crepitant rale is not observed. 
This is due to the small size of the air vesicles at this age. I have 



502 PNEUMONITIS. 

now and then detected it in quite young children, in whom it is 
a finer rale than in the adult. If observed, it is, of course, positive 
proof of the existence of pneumonitis. The physical signs, there- 
fore, in the first stage of the inflammation are often obscure in 
consequence of the absence of the pathognomonic rale. The vesicu- 
lar murmur is somewhat intensified through the chest, and there 
is in this stage slight dulness on percussion over the seat of the 
inflammation due to engorgement of the vessels, but it is difficult 
to appreciate this. 

In the second stage, which supervenes more or less rapidly, the 
physical signs are more distinct. Bronchial respiration is in most 
cases detected, higher in pitch than the vesicular murmur, with 
the sound of expiration higher than that of inspiration. The voice 
of the patient is transmitted to the ear applied over the seat of the 
disease, and often a peculiar vibratory sensation is communicated 
to the hand applied over the part, so that it is possible to locate 
the disease by palpation alone. There are frequently, in the second 
stage, and sometimes in the first, coarse mucous rales in various 
parts of the chest from coexisting bronchitis. 

Percussion, in the second stage, elicits a dull sound as compared 
with that produced on the opposite side of the chest. The dulness 
corresponds in extent with the solidification, and with the bronchial 
respiration. 

As the inflammation abates, the dulness on percussion gradually 
diminishes, and the bronchial respiration is succeeded by the 
subcrepitant rale. Often, for a considerable period after convales- 
cence is established, moist rales are observed in the chest, and 
sometimes the dulness on percussion does not entirely disappear 
till after the health is fully restored. 

In catarrhal pneumonitis the physical signs are not so distinct. 
This is due in part to the limited extent of the inflammation, in 
part, in many cases, to its subacute character, and in part to the 
fact that this inflammation is apt to be double, especially in those 
frequent cases in which the cause of the disease is hypostatic 
congestion. 

Diagnosis. — In the adult, pneumonitis is a disease of easy diagnosis. 
In infancy and childhood, on the other hand, diagnosis is often 
difficult. Acute primary pneumonitis in young children is apt to 
be confounded with meningitis or one of the essential fevers if the 
examination be made within the first or second day. In children 
over the age of three or four years, it is most frequently mistaken 
for remittent fever. The two diseases do, as regards symptoms, 



DIAGNOSIS. 503 

resemble each other. Both are characterized by great elevation of 
temperature, rapid pulse, languor, and drowsiness, and in both 
there is apt to be a cough even from the first day. But remittent 
fever (I include for the present under this term also typhoid fever) 
usually begins more gradually than pneumonitis. It is preceded 
for a few days by symptoms of mild indisposition, though there 
are exceptions, and it may commence quite abruptly. The expira- 
tory moan occurring in pneumonitis in most cases by the second 
or third day is a symptom of great diagnostic value. But positive 
proof of the nature of the disease is afforded only by auscultation 
and percussion. Scarlet fever, in its commencement, bears some 
resemblance to acute primary pneumonitis. The points of differ- 
ential diagnosis are the redness of the buccal membrane and the 
fauces, and the efflorescence upon the skin in scarlet fever on the 
one hand, and on the other the rational and physical signs of 
pneumonitis, which have been described. 

Greater difficulty attends the diagnosis of acute pneumonitis 
from bronchitis and pleuritis. The presence of the expiratory 
moan, if it is pretty constant and marked, is sufficient to exclude 
bronchitis, unless as a complication, but the physical signs con- 
stitute the only reliable means of exact diagnosis. The presence 
or absence of bronchitis is readily determined by auscultation. 
The physical signs should be carefully noted, in order to deter- 
mine if there is some point of solidification. 

Solidification gives rise to dulness on percussion, bronchial 
respiration, and bronchophony. These three signs coexisting 
afford sufficient proof of pneumonitis, unless there is tubercular 
consolidation or possibly collapse supervening on suffocative bron- 
chitis. The history of the case aids in determining whether there 
is either of these diseases. Moreover, collapse occurs later after 
the attack commences than hepatization, and does not produce so 
distinct bronchophony or bronchial respiration as are observed in 
the common form of pneumonitis. 

Pleuritis with effusion may present physical signs which bear 
considerable resemblance to those in pneumonia ; but in pneumonia, 
except when associated with tubercular deposit, the dulness on 
percussion is not so great as that from pleuritic effusion, nor does 
the line of dulness vary according to the position of the child. In 
pleuritic effusion in a young child, the respiratory murmur can 
often be heard with the ear applied over the liquid, but it is 
indistinct, and transmitted through the liquid from a distance. 
The practised ear is able to discover the difference between it and 



504 PNEUMONITIS. 

the bronchial respiration of pneumonitis. Attention to these facts 
enables us to make a positive differential diagnosis in most cases. 
Occasionally the physical signs indicate the coexistence of pneu- 
monitis and pleuritis. 

In catarrhal pneumonitis, it is often difficult to determine cer- 
tainly the nature of the disease, since the physical signs, if there 
is but little extent of inflammation, are absent or indistinct. I 
have often, in post-mortem examinations, found so small a part of 
the lung hepatized that it could not possibly have produced any 
appreciable dulness on percussion, bronchial respiration, or bron- 
chophony. Such cases are apt to pass for bronchitis, and, practi- 
cally, this matters little, since the treatment required by the two is 
not dissimilar. 

Prognosis. — Primary pneumonitis, affecting only one lung, if 
properly treated, in most instances terminates favorably in children , 
and even in infants. If double, it is, as in the adult, much more 
serious, and, in a large proportion of cases, fatal. Secondary 
pneumonitis, pneumonitis occurring in measles, hooping-cough, 
tuberculosis, or resulting from hypostatic congestion in the course 
of some exhausting disease, is, on the other hand, more frequently 
fatal. As death usually occurs from asthenia, the younger the 
child, and more feeble the constitution, the greater the danger. 

Unfavorable symptoms are a pulse becoming more and more 
frequent and feeble, pallor of countenance, inability of the patient 
to support the head, total loss of appetite, refusal to notice or be 
amused by playthings, absence of tears when crying — a symptom 
which the French writers have pointed out — and the appearance 
of pemphigus on the face or elsewhere. 

Indications on which a favorable prognosis may be based are 
moderate acceleration of pulse, pneumonitis primary and limited to 
one side, ability to support the head or sit erect, being amused by 
playthings, etc. 

Treatment. — The treatment of the two forms of pneumonitis, 
croupous and catarrhal, the former for the most part primary and 
acute, and the latter secondary and often subacute, requires to 
be considered separately, as much as do their symptoms and 
anatomical characters. In croupous pneumonitis, if seen at the 
commencement or within a few hours of the commencement, an 
emetic of ipecacuanha may be given, as recommended by Trousseau. 
This acts promptly as a cardiac sedative, diminishing somewhat 
the afflux of blood towards the lungs, and moderating the inflam- 



TREATMENT. 505 

mation. It should never be employed except at the period 
mentioned. 

If the previous health of the patient has been good, his age above 
three years, and if the inflammation is, in part at least, in the first 
stage, aconite or veratrum viride, properly employed, is serviceable. 
Either one is an efficient substitute for bloodletting. Some prefer 
aconite as less depressing than veratrum, and it is known to be a 
favorite remedy of homceopathists. I have ordinarily employed 
the veratrum, prescribing the tincture in doses of one drop every 
three hours to a child of Rve years. It can be given dropped in 
sweetened water or in the syrup of tolu. Its effect should be care- 
fully watched, and it should be omitted, or given less frequently, 
when the pulse is reduced to near the natural frequency. The 
pulse should be maintained two or three days, dating from the 
commencement of the attack, at about its natural frequency, but 
never below it. 

If bronchial respiration, bronchophony, and dulness on percus- 
sion are present, indicating the second stage ; in other words, if it 
appear from the signs that the inflamed lobe or lobes are hepatized, 
little benefit accrues from the use of so powerful a sedative, and 
much harm may be done. When this medicine is discontinued, 
or without its use, if the physician is not called till the stage of 
hepatization, a minute dose of tartrate of antimony and potassa 
should be prescribed in the class of cases to which I allude. It 
may be advantageously combined with sulphate of morphia, if the 
respiration is painful or cough troublesome. The following formula 
I have sometimes employed with a satisfactory result, for a child 
of ^.ve years : — 

R. Morph. sulph., 

Antim. et potas. tart aa gr. j ; 
Syr. bal. tolut. ^iv. Misce. 

Dose, one teaspoonful from two to four hours. In place of this, 
Dover's powder may be administered in combination with nitrate 
of potash. There soon arrives a period when depressing remedies 
should be omitted. Many now recover with simple mucilaginous 
drinks or mild expectorants, like syrup of squills or ipecacuanha 
in small doses. Others require more sustaining measures, and for 
such carbonate of ammonia with the syrup or decoction of senega 
is preferable. 

The treatment described above is proper only for robust children 
with primary pneumonitis. In no other cases are measures so 
depressing required. There can be no doubt that the great error, 



506 PNEUMONITIS. 

in the therapeutic management of children with this disease, has 
been the employment of medicines which reduced the strength, 
when gentler measures, or those of a sustaining nature, were 
required. In secondary pneumonitis or primary if the patient is 
pallid, scrofulous, or at all wasted, or under the age of three years, 
neither aconite, veratrum viride, nor antimony should be given. 
Such cases require milder therapeutic agents, as syrup of squills 
or ipecacuanha in the first stages, and, subsequently, carbonate of 
ammonia with senega. Some are best treated with ammonia and 
senega from the commencement. 

The bowels should be kept open, as an important part of the 
treatment of croupous pneumonitis in its first stages. A small 
dose of castor oil, Rochelle salts, or citrate of magnesia should be 
given if there is any tendency to constipation, and repeated from 
time to time if required. A saline aperient by its derivative and 
refrigerant effect in some cases obviates the necessity of employing 
cardiac sedatives. 

Local treatment is required in all cases; counter-irritation 
should be produced as soon as possible over the inflamed lobe, by 
mustard, iodine, or some stimulating liniment, and, except at the 
time of this application, the chest should be constantly covered 
with an emollient poultice, or with a cloth wrung out of warm 
water and covered with oil-silk. I prefer, however, the constant 
application, under the oil-silk, of the following poultice, made large 
but thin as the cover of a book and therefore light. 

]}.. Puly. sinapis. ^ss; 

Pulv. semin. lini ^viij. Misce. 

In a large proportion of cases, vesication is not required. If the 
inflammation is extensive, and the symptoms urgent, it is occa- 
sionally advisable to blister, and the cantharidal collodion should 
be used for this purpose. A safe, almost painless, and at the same 
time efficient, mode of applying this is in spots as large as a ten 
cent piece, half a dozen, more or fewer according to the extent of 
the inflammation, the skin of course remaining sound between 
them. This mode of application obviates the danger of producing 
a troublesome sore, which sometimes occurs in children from the 
ordinary mode of vesication. 

The diet should be nutritious, consisting of animal broths and 
the like, unless during the first three or four days, in robust chil- 
dren. 

In those few cases of croupous pneumonitis which occur in 
young children, no remedy should be employed more depressing 



PLEUEITIS. 507 

than ipecacuanha, perhaps combined with some aperient like 
castor oil. as in the formula recommended in the treatment of 
bronchitis. 

Before leaving the subject of the therapeutics of pneumonitis, 
I desire to impress upon the reader the paramount importance of 
ascertaining fully, before he prescribes, not only the extent and 
stage of the inflammation, but especially the condition of the 
patient's constitution. For many cases require sustaining measures 
from the first, and, without a proper appreciation of the patient's 
state, the medicines ordered may be highly injurious instead of 
useful. 

Catarrhal pneumonitis requires somewhat different treatment, 
not only because it occurs chiefly in infancy and early childhood 
when there is little vigor of constitution, but because it is as a 
rule secondary. In acute catarrhal pneumonitis, which, as we have 
seen, in most instances results from an active bronchial inflamma- 
tion, the treatment already employed for the primary disease should 
be continued. (See Art. Bronchitis.) If there is pain or restless- 
ness, a little opiate should be added. In subacute forms of the 
disease, and in the acute when it has continued a few days, sus- 
taining and even stimulating measures are indicated; carbonate 
of ammonia with some tonic is useful in such cases. 

In cheesy pneumonitis, or in protracted catarrhal pneumonitis 
which may or may not have become cheesy, carbonate of ammo- 
nia in combination with citrate of iron and ammonia, equal parts, 
or cod-liver oil to which two or three drops of syrup, ferri iodidi 
are added, will be found useful, as are also alcoholic stimulants. 
Nutritious diet is required in all cases of catarrhal pneumonitis. 
The local treatment should consist of an oil-silk jacket and coun- 
ter-irritation, as recommended in the treatment of croupous pneu- 
monitis, without vesication. In case of hypostatic pneumonia the 
position of the patient should be frequently changed. 



CHAPTER YI. 



PLETJRITIS. 



Pleueitis occurs both as a primary and secondary disease. If 
we except such cases as are due to pneumonitis and tubercles, secon- 
dary pleurisies are more common in children than in adults. 



508 PLEURITIS. 

Causes. — The ordinary cause of primary pleuritis is the same as 
that of most primary inflammations, namely, the impression of cold. 
It is therefore most common in the cold months, and in times of 
changeable temperature. Cachexia is a predisposing cause. There- 
fore, children whose blood is impoverished by the anti-hygienic 
conditions in which they reside, or by previous disease, are more 
liable to it than those who have robust constitutions. Hence, also, 
its frequency among foundlings and the children of the city poor. 

The causes of secondary pleuritis are quite numerous. The most 
common, after the age of three years, are tubercles, pneumonitis, 
and scarlet fever. Tubercles cause pleuritis by their irritating 
effect upon the pleura, and of course only those tubercles can 
produce this result which are seated directly underneath this 
membrane. Pneumonitis causes pleurisy by extension of the in- 
flammation. Scarlet fever gives rise to it indirectly as a sequel. 
In a certain proportion of cases of this exanthem, during the period 
of desquamation or convalescence, active congestion or inflamma- 
tion of the kidneys occurs, giving rise to uraemia. Urea in the 
blood is an irritant to serous structures, and hence is a not infre- 
quent cause of pleuritis. 

In the infant many cases of pleuritis are due to the escape or 
discharge into the pleural cavity of some pathological product, 
usually pus, softened tubercle, or decomposed lung tissue. This 
substance is an irritant, and it produces acute and often general 
pleuritis. A very small amount of pus or softened tubercle, or of 
decomposed lung escaping into the pleural cavity, gives rise to 
violent and fatal pleurisy. I have made post-mortem examinations 
of several such cases. 

A retro-pharyngeal abscess in rare instances descends behind 
the pharynx and oesophagus, and opens into one of the pleural 
cavities, causing fata] pleuritis. A suppurated bronchial gland, or 
an abscess in the walls of the chest, occasionally produces the 
same result. In January, 1864, I presented to the New York 
Pathological Society the lungs of an infant with the following 
history: E., nine months old, of German parentage, family scro- 
fulous. Its own health was good prior to the sickness of which 
it died, and it was fleshy. The only other child in the family, a 
girl, had suffered from strumous ophthalmia and strumous peri- 
ostitis of the tibia. This infant was taken sick about December 
19th, 1863, with moderate febrile movement and restlessness, but 
apparently without any serious indisposition. On the 22d of 
December, the mother called my attention to a prominence just 



CAUSES. 509 

below the right clavicle. This proved to be an abscess. A poultice 
was applied, in the expectation that it would discharge external^. 
On the 24th of December, however, the prominence subsided, and 
immediately the symptoms were greatly aggravated. The pulse 
rose to 160 per minute, the respiration to 60 or 80, and expiration 
was accompanied by a moan, so common in acute inflammation of 
the pleura or lung. "Within a day or two after the disappearance 
of the tumor, and the exacerbation of the symptoms, dulness on 
percussion was observed on this side, and this increased till there 
was perfect flatness. The right pleural cavity had evidently filled 
with liquid, the acceleration of pulse and respiration continued, 
the patient grew more and more feeble, and death occurred De- 
cember 31st. 

At the autopsy, on dissecting away the integument from the 
right side of the chest, an abscess was opened, containing nearly 
an ounce of pus, located at the point where the tumor had been 
observed. There was a small round opening from this abscess 
directly into the cavity of the chest, so that, on depressing the ribs, 
liquid escaped from the cavity. On removing the sternum, the 
liquid was found to consist mainly of serum with lymph, and at 
the bottom of the liquid was considerable pus. I have met one 
other case, apparently almost identical with this, the infant being 
seven months old, but I did not attend it in the latter part of its 
sickness. The abscess in the case which I have detailed was ob- 
viously strumous, probably occurring from glandular inflammation. 
This mode of production of pleuritis, namely, by the discharge of 
an abscess located in the thoracic walls, is no doubt rare. It was 
so considered by the members of the Pathological Society. Pleu- 
ritis, which is a common accompaniment of croupous pneumonitis, 
is not common in the catarrhal form of the disease, and therefore 
cases due to pulmonary inflammation are less frequent in children 
than in adults. But inflammation of the pleura occasionally 
occurs in catarrhal pneumonitis in the following manner: Little 
abscesses are produced in the solidified lung, containing from one 
or two to as many as fifteen or twenty drops of pus, as has been 
stated in our remarks on pneumonitis. The pus, approaching the 
pleural surface, produces circumscribed pleuritis at that point, or, 
opening into the pleural cavity, it gives rise to general pleuritis, 
with or without pneumothorax. The following cases, among others 
which I could present, established this point. These cases are also 
interesting, as showing the occasional latency of pneumonitis. 



510 PLEURITIS. 

Case 1. — I. M , male infant, was admitted into the Nursery and 

Child's Hospital, May 19th, 1859, at the age of two months. He was 
very delicate at the time of admission, and had slight bronchitis, but, 
being placed with a wet-nurse, he gradually improved. About the middle 
of July, attacks of diarrhoea occurred, each lasting from one to two days, 
and from this time his health declined. Furuncular eruptions appeared 
on the head and neck, and, though sustaining measures were employed 
with medicines to control the diarrhoea, there was progressively more 
emaciation and feebleness. 

The records on August 1st state, "Continues to fail, apparently from 
the attacks of diarrhoea; the furuncular eruption continues." On the 
3d of August, he died suddenly of apnoea, though there had been no 
symptoms to direct attention to the chest. Possibly he had a slight 
cough, which had escaped detection. 

Autopsy eight hours after death. — Stomach and jejunum healthy ; 
mucous membrane lining the lower part of the ileum and the entire 
colon vascular, and that of the colon considerably thickened ; mesenteric 
glands enlarged, and of a lighter color than in health ; right lung com- 
pressed by a sero-fibrinous exudation, so as to occupy a small space, 
though the amount of liquid was not more than two ounces ; nearly the 
entire pleura, visceral and parietal, on this side was covered with a fibri- 
nous deposit of a creamy appearance. Some of this had settled in the 
depending portion of the cavity. This lung could be inflated, except a 
little of the lower lobe, which was hepatized. 

On the left side, the lung also occupied a very small space, being col- 
lapsed; the upper lobe could be readily inflated when it had the elasticity 
of healthy lung; the lower lobe had a healthy appearance, and could be 
inflated, except a portion in the posterior aspect measuring, perhaps, an 
inch in diameter ; this was partially coated with lymph, and was found 
to contain two small abscesses, one closed, the other opening externally 
on the surface of the lung and internally into a bronchial tube. On 
attempting inflation, the air passed directly through this opening. The 
closed abscess contained from one-third to half a drachm of pus cor- 
puscles, and disintegrated lung tissue, as shown by the microscope. 
The child was much emaciated. 

Case 2. — M. I , female, was admitted into the Child's Hospital 

October 7th, 1859, at the age of about four months; at the time of admis- 
sion, was somewhat wasted with diarrhoea; her health improved partially, 
but she remained feeble, and was at times much troubled with meteorism 
which occasioned pain. 

On the 2d of November, she was suddenly seized with great dyspnoea, 
which terminated fatally in about a quarter of an hour. Previously to 
the dyspnoea, no cough had been noticed, or other s} T mptoms referable 
to the chest. 

Autopsy. — Body considerably emaciated ; left lung healthy, with the 
exception of slight hypostatic congestion; right lung adherent to the 
diaphragm, and to a considerable part of the costal pleura, by fibrinous 
exudation; this lung was somewhat compressed and non-crepitant; the 
upper lobe floated in water; the middle and lower sank and could not 
be inflated, or but slightly; this portion of the lung contained a few 
small abscesses, filled with purulent matter, each holding scarcely more 
than one drop; two of these seemed to have discharged into the pleural 
eavit}', as the air passed through them in attempting to inflate, but 
possibly they may have been opened in separating the adhesions which 



ANATOMICAL CHARACTERS. 511 

united the two pleural surfaces at this point ; two or three ounces of 
fluid were contained in the pleural cavity, consisting, in addition to 
serum, of fibrinous flocculi, epithelial cells from the pleura, pus cells, 
and compound granular cells: the lower portion of this fluid, on stand- 
ing, contained so much pus that it presented the characteristic gelatinous 
appearance on the addition of liquor potassse; the other organs generally 
were normal in appearance, but the liver was somewhat congested, and 
there was also decided hyperemia of the mucous membrane of the colon 
near the ileo-coecal valve, and in the descending portion. 

In cases like the above, the pleuritis is obviously due either to 
the escape of pus from the lung into the pleural cavity, or to its 
near approach to the pleura. In the former case the inflamma- 
tion is apt to be general; in the latter circumscribed. The above 
cases are interesting, as showing an occasional result of circum- 
scribed pneumonitis in the infant, namely, hydrothorax in addition 
to pleuritis. 

Sometimes, especially in young children, the cause of the pleuritis 
is apparently general, or constitutional, but is obscure. Thus, at 
the autopsy of an infant who died at the age of about one month 
in the Infant's Service of Charity Hospital, in 1867, a small amount 
of pus, not more than a drachm, was found in one pleural cavity, 
and less than this quantity in the other. On both sides there was 
nearly general injection of both the visceral and costal pleurse, but 
without exudation of serum or fibrin. There was pus also at the 
roots of the lungs, extending somewhat over the lungs but under 
the pleura. The fact of a double pleurisy appeared to indicate a 
constitutional cause, but there was no apparent cause of this nature 
except cachexia, to which allusion has already been made, as predis- 
posing to this form of inflammation. 

Anatomical Characters. — The first appreciable structural 
change which occurs in pleuritis is engorgement of the vessels 
lying underneath the pleura. There can be seen, if an opportunity 
is presented, as in the case detailed above, a network of engorged 
capillaries. Immediately exudation commences into the connec- 
tive tissue surrounding the capillaries, the pleura becomes opaque, 
and liquor sanguinis escapes on its free surface. The amount of 
serum and fibrin which is exuded into the pleural cavity varies 
greatly in different cases, as does their relative proportion. 

In pleuritis due to the irritation of tubercles, or to extension of 
inflammation from an inflamed lung to the pleura which covers it, 
the amount of serum is ordinarily small, and occasionally almost 
entirely absent, so that the visceral and costal surfaces remain in 
contact. In other cases, namely, when the pleuritis is idiopathic, 



512 PLEURITIS. 

or due to uraemia, or to a foreign substance in the pleural cavity, 
the amount of serous effusion is considerable, producing more or 
less compression of the lung. The most frequent exceptions to 
these general statements I have observed in the pleurisy of tuber- 
culosis in infants, in which form of the disease the lung is not 
infrequently somewhat compressed by the liquid. 

Ordinarily the fibrin forms a layer over the inflamed pleura, at 
first soft and readily detached, but gradually becoming firmer, and 
shreds or flocculi of fibrin, becoming separated, float in the exuded 
serum. "When the inflammation has continued a short time, 
granulations appear on the inflamed surface, receiving their supply 
of blood from the sub-pleural capillaries, which have been pro- 
longed. These granulations, when the serum is absorbed, uniting 
with those on the opposite side, form permanent adhesions. 

Pleuritis, except when due to a local cause seated beneath the 
pleura, as tubercle or pneumonitis, extends rapidly, soon becoming 
general. 

In a certain proportion of cases empyema occurs. The propor- 
tion of pleurisies in feeble and ill-conditioned infants which are or 
become suppurative is very large. Hence empyema, as I have often 
noticed, is not infrequent in the institutions of this city where such 
infants are treated. As, in recent fatal cases, we find the exuda- 
tion mainly sero-fibrinous, and empyema in those who have lived 
a month or more, it has seemed to me that the suppuration is 
probably referable to the irritating effect of the fibrin, which, 
liquefying, and not absorbed on account of the general feebleness, 
acts as an irritant, and provokes a suppurative inflammation. 

Pleuritis has, for convenience of description, been divided into 
three stages : the first, extending from the commencement of the 
inflammation to the time when there is an appreciable amount of 
exudation; the second, from the time that the exudation is appre- 
ciable to the commencement of absorption ; the third stage is that 
of absorption or convalescence. Absorption commences when the 
inflammation abates, and the rapidity with which the fluid dis- 
appears varies greatly in different cases. As absorption occurs, 
the compressed lung gradually expands to occupy the place of the 
fluid. Sometimes absorption occurs more rapidly than the expan- 
sion, so that there is depression for a time of the thorax on the 
affected side, which gradually disappears. The serum is first 
absorbed, and then the fibrin, undergoing fatty degeneration and 
liquefaction, is also absorbed. Occasionally portions, of the fibrin 
instead of being absorbed undergo calcification, after which there 



SYMPTOMS. 513 

is no farther change. Commonly, as the serum is removed the two 
pleural surfaces become permanently adherent, and the lobes are 
likewise united to each other. 

In rare instances, in which there is a large amount of serous 
exudation, producing complete carnincation of the lung, and 
absorption is slow, inflation never occurs, and the ribs of the 
affected side are permanently depressed. Respiration henceforth 
is performed entirely by the other lung, which increases somewhat 
in volume by hypertrophy of the air cells. The compressed lung 
remains non-crepitant and firm, and its color somewhat lighter 
than the natural hue, from defective supply of blood and granular 
change in its anatomical elements. 

In empyema, absorption obviously cannot occur unless the 
quantity of pus is small. Empyema, therefore, except when re- 
lieved by paracentesis, is a lingering disease, attended by many of 
the symptoms of tuberculosis. Spontaneous cure occasionally 
occurs, by discharge of pus into a bronchial tube, or externally 
through the walls of the chest. I have witnessed both these 
modes of termination. In certain instances, pleuritis on the left 
side becomes complicated with pericarditis, and, more rarely, pleu- 
ritis in the lower part of the right pleural cavity, with perihepatitis, 
the inflammation extending in the one case through the pericar- 
dium, in the other through the diaphragm. I have met four cases 
of the former complication, and one of the latter in infants. 

Symptoms. — Occasionally pleuritis is latent. This may be its 
character, both in the primary and secondary form, latency being 
more frequent in infancy than in childhood. The following is an 
example. A feeble infant, 5 months 28 days old, died suddenly 
at the Nursery and Child's Hospital, December 29th, 1870. The 
attention of the resident physician had not been called to it, as it 
was not supposed to be sick, although its general condition was 
bad, and the attendant nurse who had charge of the ward denied 
that there was any symptom, unless possibly an occasional slight 
cough in the last three or four days. Percussion over the right 
side of the chest of the corpse gave a flat resonance, and the right 
lung was found at the autopsy carnified and covered with a loose 
fibrinous layer, in places three-fourths of an inch thick. 

As circumscribed pleurisy is for the most part a secondary dis- 
ease, the symptoms which are present are due partly to it and 
partly to the primary affection. Obviously the symptoms vary in 
different cases, according to the presence or absence of other dis- 
eases, the age and robustness of the patient, and the extent of the 
33 



514 PLEURITIS. 

inflammation. In most cases the commencement of pleuritis is in- 
dicated by increase in the frequency of the pulse and respiration, 
the expiratory moan, and sometimes by tenderness on percussion 
over the seat of the inflammation. There is a short cough, dry or 
hacking, unless bronchitis coexists, in which case there is more or 
less expectoration ; at the same time, those symptoms are present 
which are common in all inflammatory affections, such as anorexia, 
thirst, and increase of temperature. The symptoms enumerated, 
though commonly so severe as to draw attention at once to the 
chest, are in other cases so mild, even when the inflammation is 
not latent, that they may be at first overlooked. There is, indeed, 
every gradation between severe symptoms and latency. 

In acute general pleuritis the symptoms are commonly severe. 
The pulse rises to 130 or 140 beats per minute, and in young 
children it may be more frequent ; the respiration is increased in 
a corresponding degree ; the face is flushed and indicative of suf- 
fering; the patient is restless, complaining, if old enough to speak, 
of the stitch-like pain in the chest, which is most intense on in- 
spiration and in coughing. The mean temperature, according to 
the observations of Mr. Squire, is 101° Fahr. 

When exudation occurs the symptoms abate partially. The 
pulse and respiration are less frequent, though still accelerated, and 
the latter is less painful. Convalescence is more protracted in 
pleuritis than in pneumonitis. Several weeks frequently elapse 
before the liquid is fully absorbed, during which time there is more 
or less acceleration of pulse. The appetite and strength return 
gradually. 

In suppurative pleuritis or empyema, the symptoms may not 
differ materially at first from those in the ordinary form of inflam- 
mation, but absorption does not occur, or there is but a slight de- 
gree of it, limited to a portion of the liquor puris. The pus produces 
the ordinary effects of purulent collections in the system, namely, 
loss of appetite, hectic fever, emaciation, loss of strength. No im- 
provement occurs except by discharge of pus, when restoration to 
health is often rapid. In fatal cases of empyema the vital powers 
gradually yield, the pulse becomes more frequent and feeble, the 
face and limbs pale and cool, and death occurs from asthenia. 

Physical Signs. — The physical signs vary according to the ex- 
tent of the inflammation, and the amount of exudation. The fric- 
tion sound is seldom observed in the infant, and it is less frequently 
heard in the child than in the adult. 

Percussion, in the commencement of pleuritis, before there is any 



PHYSICAL SIGNS. 515 

appreciable exudation, gives a negative result. If dulness is ob- 
served, it is due to coexisting disease, commonly pneumonitis or 
tuberculosis. In those cases in which, no effusion of serum occurs, 
or in dry pleurisy, as it is termed, percussion at all periods of the 
disease gives only negative information, impaired resonance if 
present being due to the pulmonary disease, pneumonitis or tuber- 
cles, to which this form of pleurisy is commonly due. In a large 
proportion of circumscribed pleurisies the percussion sound is not 
materially affected. 

If there is serous effusion, and this occurs in most pleuritic 
attacks which are not dependent on pulmonary disease, and some 
in which there is this dependence, percussion over the liquid 
elicits a flat sound, while the resonance above the level of the 
liquid is good, and occasionally even tympanitic. Flatness on per- 
cussion distinguishes pleuritic effusion from simple pneumonitis, 
since in pneumonitis percussion produces a dull, but not flat, sound. 
In young children in whom pneumonitis is catarrhal and limited 
to a part of a lobe, the difference is very marked. Change in the 
height of the flatness, according to the position of the patient, is 
observed injnfancy and childhood, not less than in adult life. 

When the second stage commences, and the pleural cavity con- 
tains more or less liquid, the respiratory sound often disappears 
from the part of the chest which is occupied by the liquid in chil- 
dren over the age of five or six years, but in a large proportion of 
cases in the first years of childhood, and usually in infancy, in 
which period the pleural cavity is small, respiration is heard with 
the ear applied over the liquid. It is transmitted from a distance. 
Its character is bronchial, broncho-vesicular, or even sometimes 
vesicular. It appears in certain cases, especially when vesicular, 
to be transmitted from the opposite side of the chest. 

It varies in its intensity, according to the amount of the liquid 
and the strength and rapidity of the respiration. It sometimes, 
according to Rilliet and Barthez, partakes of the cavernous respi- 
ratory sound, so that, in the first case in which they observed this 
modification, their diagnosis was erroneous. There was complete 
restoration to health, with absorption of the fluid, although they 
had diagnosticated a cavity. 

If there is a large amount of fluid and the lung is compressed 
at the top of the pleural cavity, bronchial respiration may be heard 
above the level of the fluid, in the infra-clavicular region. In the 
adult this is a common physical sign. ^Egophony is occasionally 
observed in acute cases, in which there is a rapid and large effusion. 



516 • PLEURITIS. 

It is heard in the infra- and inter-scapular spaces. Its duration is 
commonly brief, disappearing in three or four days or even in less 
time. Bulging of the intercostal spaces and distension of the 
thoracic walls from the fluid are less frequent in young children, 
and especially infants, than in adults. In the infant, so readily are 
the lungs compressed, complete carnification is apt to occur, before 
the shape of the chest is materially altered. On account of these 
peculiarities as regards the physical signs and the mechanical effect 
of a liquid in the pleural cavity of a young child, physicians whose 
knowledge of pleuritic effusions is derived chiefly from the exami- 
nation of adult cases are apt to err in diagnosis. Thus, in 1870 a 
carnified lung, covered with a thick pyogenic membrane from 
which granulations had arisen, was presented by myself to the 
New York Pathological Society, with the following history of the 
case. "W"., twelve months old at the time of death, was taken sick 
at the age of six months, with fever, and a cough, which was slight 
and not frequent. At about eight months he first came under ob- 
servation. The infant was then small for its age, pallid and thin. 
The two sides of the chest measured the same, and on both sides 
the intercostal spaces were somewhat depressed, but percussion 
over the right side produced a flat sound, showing that the air was 
wholly excluded from the right lung. The respiration upon the 
affected side was bronchial and distinct. Two well-known physi- 
cians of this city, thorough in their examinations, and usually 
accurate in diagnosis, examined this case in reference to the pro- 
priety of thoracentesis, and both expressed a decided opinion that 
the pathological state was not a pleuritis, but either collapse or 
interstitial pneumonitis, one of them observing, as he thought, in 
addition to the physical signs already stated, bronchophony. The 
febrile movement was moderate, and no decided hectic was observed. 
Death occurred from exhaustion. At the autopsy about half a 
pint of thick pus was found in the right pleural cavity, producing 
complete carnification of the lung. The pus, which, considering 
the stunted growth of the child and small size of the pleural cavity, 
was considerable, had evidently lost part of the liquor puris by ab- 
sorption. 

The following case, which shows how deceptive the physical 
signs may be in young children in cases of suppurative pleuritis, 
will repay perusal, since the life of the patient depends in great 
part on a correct understanding of his condition, so that appropriate 
measures will be employed : — 



DIAGNOSIS. 517 

Case. — H — , boy four years four months old, was taken with scarlet 
fever in the latter part of May, 1868. It was severe, and was attended 
with inflammation of the glands and connective tissue of the neck, with 
suppuration on both sides. Purulent discharges from the abscesses 
continued through the month of June. The patient was gradually con- 
valescing, when, about July 4th, pleuritis commenced on the left side, 
attended by the ordinary symptoms of acute forms of this inflammation. 
A few days subsequently, the pleural cavity was ascertained by physical 
examination to be about half full of liquid. 

Towards the close of July, anasarca commenced about the ankles and 
gradually extended upwards. It was limited to the lower extremities, 
and to the abdominal walls, and by the middle of August became 
excessive. The thoracic walls and the upper extremities were somewhat 
emaciated, and the face was pallid and anxious. 

On the 7th of August, a careful examination of the chest was made 
in reference to the propriety of thoracentesis. The intercostal spaces 
on the left side were not prominent, but rather depressed. Percussion 
over the lower third of the left pleural cavity elicited a flat sound, while 
above this the resonance was tympanitic. On account of the great rest- 
lessness of the patient, no useful information was derived from change 
of position. On auscultation distinct bronchial respiration was heard 
over nearly or quite the entire left side of the chest. The apex beat of 
the heart was on the right of the sternum. It was my opinion, as well 
as that of two other physicians, that the liquid was in process of absorp- 
tion, and that the quantity present was not large. Thoracentesis did 
not, therefore, seem a proper measure. 

The anasarca still limited to the lower extremities, and the abdominal 
walls continued to increase, and on the 25th of August, so great was the 
distension, that the skin broke in one or two places above the ankles. 
The mind remained clear, and the appetite was pretty good. Death 
occurred August 27th. 

Sectio Cadaver. — Head not examined ; abdominal and right pleural 
cavities contained no effusion, and were in their normal state, except 
that the latter cavity was somewhat encroached upon by the heart and 
mediastinum; a great amount of oedema in the lower extremities and in 
the abdominal walls; abdominal walls towards the spine about three 
inches thick, in consequence of oedema; right lung of good size, and pre- 
senting the ordinary appearance except a greater amount than usual of 
hypostatic congestion; about three pints of pus (laudable) in the left 
pleural cavity; left lung completely carnified and lying against the 
vertebral column, its size about that of an orange, and its surface 
covered with a dense layer of fibrin ; heart displaced, as already stated, 
to the right, and a little downward, so as to compress and partially 
obstruct the circulation in the ascending vena cava; this vessel con- 
tained a continuous, firm and yellow fibrinous clot, nearly filling its 
calibre; the femoral vein, examined on one side, was found to contain 
soft and dark clots. Compression of the cava opposite the heart and 
the formation of clots had evidently given rise to the anasarca. 

Diagnosis. — This is in certain cases readily made, but in others, 
as we have seen, is attended with difficulty. It is more difficult 
in those under than over four or live years. Partial or circum- 
scribed pleuritis, attended by little or no serous exudation, is more 



518 PLEURITIS. 

apt to be overlooked than other forms of the inflammation, but, as 
it is ordinarily due to graver disease of the lungs, its detection 
is not very important. The points involved in its diagnosis are 
acceleration of pulse and respiration, increase of temperature, 
expiratory moan, friction sound, and tenderness on percussion. 

The diagnosis of acute general pleuritis in its commencement, 
before the stage of effusion, is attended with some difficulty. It is 
most likely to be mistaken for pneumonitis, since the prominent 
symptoms in the commencement of the two diseases are similar. 
There is, however, in pleuritis ordinarily greater acceleration of 
pulse and respiration, greater elevation of temperature, greater 
suffering, as indicated by the features, and a more decided expira- 
tory moan. It will aid in the differential diagnosis, in children 
under the age of five years, to recollect that acute pneumonitis is 
in most instances preceded by bronchitis, which is not the case 
with acute pleuritis, except as a coincidence. 

Pleuritis with effusion could only be mistaken for pneumonitis 
or hydrothorax. But the loss of resonance on percussion in cases 
of pleuritic effusion is much greater than when the lung is solidified 
from pneumonitis. The physical signs, which are involved in the 
differential diagnosis of these diseases in the adult, are important, 
also, for diagnosis in children, though, as we have seen, they are 
less constant and less reliable in young children than in adults. 
In children over the age of fiYe years they are pretty uniformly 
present. The signs alluded to are bulging of the intercostal spaces, 
expansion and subsequently retraction of the chest, evidence of 
change in the height of the fluid, by change in the position of the 
body, no bronchophony and fremitus as in pneumonitis, etc. Hy- 
drothorax in the child commonly results from one of the eruptive 
fevers, especially scarlatina, and its immediate cause is nephritic 
congestion or inflammation, or heart disease. Rarely it is due to 
obstruction in the pulmonary circulation, in consequence of enlarged 
bronchial glands. It is not, therefore, preceded nor accompanied 
by symptoms of inflammation referable to the chest, as in cases of 
pleuritic effusion. 

Empyema may be diagnosticated from the fact that there is 
little or no diminution in the amount of liquid after several weeks 
have elapsed, and from the febrile movement, loss of appetite, flesh, 
and strength, which attend all large purulent collections. 

Prognosis. — Primary pleuritis, occurring in patients previously 
healthy, commonly ends favorably ; but it is a serious disease if 
the general health has been much impaired. The prognosis is 



TREATMENT. 519 

more favorable if, as is commonly the case with this form of 
pleurisy, the patient is over the age of three or four years. 

Secondary pleuritis is, on the other hand, a grave affection, but 
the prognosis depends greatly on the character of the primary dis- 
ease, and also on the age. Pleurisy resulting from and coexisting 
with pneumonitis commonly ends favorably even in quite young 
patients. Pleuritis arising from scarlet fever is apt to be suppura- 
tive, and is, therefore, a serious complication or sequel, but a 
considerable proportion affected with it recover under judicious 
treatment. The prognosis in tubercular pleuritis and pleuritis 
occurring from the escape of pus into the pleural cavity is obviously 
unfavorable. 

Tubercular pleuritis may be temporarily relieved, but it is apt 
to return. Suppurative pleuritis, or empyema, is also an unfavora- 
ble form of inflammation, characterized by the chronicity and 
many of the symptoms of tuberculosis. It is in time fatal unless 
the pus is evacuated. On the escape of the pus, whether spontane- 
ously or by thoracentesis, there is usually progressive and complete 
restoration to health. In case the pus is evacuated, the prognosis 
is better in children than in adults. 

Treatment. — The indications of treatment are, in the commence- 
ment of the inflammation, to diminish its intensity, and relieve 
pain ; at a later period, to promote absorption and sustain the vital 
powers. 

Pleuritis is one of the few inflammations in early life in which 
the abstraction of blood may be proper. It may be stated as a 
rule, that loss of blood is not only not required, but is an injudi- 
cious measure in all secondary pleurisies, and in the primary form 
after exudation into the pleural cavity has occurred. It is a useful 
measure at the commencement of acute primary pleuritis occurring 
in a robust state of system. One or two leeches should be applied 
directly over the seat of the inflammation, and bleeding may be 
encouraged for two or three hours subsequently by the application 
of cloths wrung out of warm water. Unfortunately the physician 
is, in many cases, not called at this early period ; or, if called, he 
fails to make the diagnosis till there are evidences of exudation. 

After bleeding has ceased, or in subacute and secondary pleurisies 
without the employment of leeches, rubefacient applications should 
be made over the affected side of the chest, followed by a poultice, 
or flannel wrung out of warm water and covered with oil-silk. 
Moderate counter-irritation diminishes the pain, but vesication at 
this early period is injurious. A blister applied so near the seat of 



520 PLEUEITIS. 

the inflammation may increase the afflux of blood towards it, and 
aggravate the disease. 

Robust patients over the age of three or four years are benefited 
by the use of cardiac sedatives in the commencement of acute 
pleuritis. The tincture of aconite or of veratrum viride may be 
given, but its effects should be carefully watched, and it should be 
discontinued when the pulse is reduced to near the natural fre- 
quency, or when sufficient exudation has occurred to produce the 
ordinary physical signs of liquid in the chest. They should not 
be given in secondary pleuritis. 

Opiates are required, as in other serous inflammations, accord- 
ing to the pain. Dover's powder, in doses of one to three grains, 
according to the age, may be given every three hours, or less fre- 
quently if the patient is inclined to sleep. 

Such is the treatment required in the first stage of acute 
primary pleuritis, or that preceding the effusion. Secondary 
pleuritis requires fewer and less depressing measures. The appro- 
priate treatment, in a large proportion of the cases of this form 
of the disease, consists in the use of an opiate, with rubefacient 
and emollient applications to the chest. Abstraction of blood, 
and powerful cardiac sedatives, as aconite and veratrum viride, 
are dangerous remedies in secondary pleurisies, and are almost 
never used. 

Pleurisies dependent on pulmonary disease, which are circum- 
scribed and attended with little serous effusion, require no other 
therapeutic measures than those already mentioned. The judi- 
cious use of opiates, and rubefacient and emollient applications, 
suffice for their treatment. 

In the treatment of other forms of pleurisy, which are attended 
by more or less effusion of liquid into the pleural cavity, measures 
designed to remove this liquid are required when the inflammation 
has abated, and antiphlogistics are no longer appropriate. 

Liquids in the great cavities are best eliminated by hydragogue 
cathartics and by diuretics. For children, however, already weak- 
ened by pleuritic inflammation, cathartics are usually too depress- 
ing unless for one or two days. ISTow and then a robust patient, 
over the age of five or six years, with pleuritic effusion, may be 
benefited by an occasional purgative dose of bitrate of potassa, or 
by from one-twelfth to one-sixth of a grain of podophyllin. But 
such cases are exceptional. In a majority of children the loss of 
strength resulting from cathartics more than counterbalances the 
good result from the liquid evacuations which they produce. 



TREATMENT. 521 

Diuretics, on the other hand, are efficient remedies, and upon 
them our chief reliance must be placed. 

The diuretic from which I have seen better effects than from 
any other is iodide of potassium, but it should be given in large 
doses. In the adult I have observed rapid absorption of the 
liquid by the administration of from one to two drachms daily of 
this agent, given in doses of ten grains, and a child can take a 
proportionate dose. Two to five grains, according to the age, may 
be given every three hours. At the same time it is advisable to 
restrict the drinks. 

At this stage of the disease counter-irritation is appropriate, 
either by rubefacients or vesicants. The preferable mode of 
blistering the child is, in my opinion, by cantharidal collodion 
applied as recommended in the treatment of pneumonitis. 

In secondary pleuritis the diet should be nutritious, consisting 
largely of animal broths, through the whole period of the disease. 

In primary pleuritis nutritious diet should be allowed after exu- 
dation has occurred. In some cases, more frequently in secondary 
than primary pleuritis, stimulants are required. In protracted 
pleurisy, or pleurisy occurring in a debilitated patient, tonics, both 
vegetable and chalybeate, are often serviceable, sustaining the 
strength while the process of absorption is going on. 

Occasionally the measures which have been recommended above 
to promote absorption of the liquid in the pleural cavity do not 
have the effect which is desired. If there is no sensible diminu- 
tion in its amount, and if the general health of the patient begins 
to fail, the performance of thoracentesis should be considered. We 
may accomplish by surgery what we fail to effect by therapeutic 
means. The following are the remarks by Prof. Flint, on this 
subject. They apply to thoracentesis in children as well as adults. 
(Flint's Practice of Medicine, 2d ed.,p. 155.) 

"Heretofore this operation was performed only as a dernier resort, 
under circumstances when little was to be expected from any 
measure. It was deferred as long as possible, sometimes on account 
of doubt as to the diagnosis, and because the perforation and 
introduction of air were supposed to involve danger of an increase 
of the inflammation. A considerable opening was necessary in 
order to give free exit to the liquid, and it was not easy to prevent 
the air from entering the pleural cavity. Objection to the opera- 
tion on the score of diagnosis is now removed by our present 
knowledge of physical signs. Moreover, the operation has been 
divested of all severity, and the liability to the introduction of air 



522 PLEUKITIS. 

has been provided against by the application of the suction pump, 
first suggested by Dr. Morill Wyman, in 1850, and since employed 
in a large number of cases by Dr. Bowditch. The introduction of 
air is not attended by the injurious effects formerly apprehended, 
but it is objectionable because the presence of air is an obstacle to 
the full expansion of the lung after the liquid is removed. Its 
introduction is prevented by the use of the pump in withdrawing 
the liquid. The operation is rendered trivial, because with the 
suction force of the pump a small exploring trocar suffices to make 
the puncture, which causes very little pain, and closes directly the 
canula is removed." 

Dr. Bowditch had performed the operation one hundred and 
fifty times on seventy-five individuals prior to 1863, in the manner 
described above, and in twenty-nine of the patients recovery was 
apparently due to it. Prof. Flint has several times successfully 
performed the operation, using a small trocar and canula made to 
screw on the flexible suction tube of Davidson's syringe. 

M. G-uersant describes his mode of performing thoracentesis, in 
the Bull. Gener. de Therap., Oct. 15,1866. He generally "plunges 
in the instrument above the superior border of the tenth rib on 
the left side, and the eighth rib on the right, and at the junction 
of the posterior one-third with the anterior two-thirds of the inter- 
costal space. He employs a trocar about two lines in diameter, 
and nearly two inches in length, curved like a tracheotomy canula 
and furnished with a flap of membrane over its external orifice. 
The child is placed upon its back, and firmly held, while the 
operator with his left hand draws upon the skin, and with his 
right inserts the trocar, with its concavity looking downwards so 
as to avoid injuring the lung. The membrane at the external 
orifice of the canula, being previously moistened, excludes the en- 
trance of air. On withdrawing the instrument, the skin passes 
over the wound, and the parts unite by first intention, provided 
that the liquid is sero-fibrinous." 

The following are my experience and views in reference to this 
operation. Thoracentesis is rarely required in the child except for 
empyema, and it should not as a rule be performed in less time 
than eight weeks after the commencement of the inflammation, so 
as to allow as much as possible of the liquid to be absorbed. If 
the health of the patient is but little impaired, it is proper to 
wait longer, for, if the effusion is largely sero-fibrinous, and the 
amount of pus small, recovery is possible by absorption, for a small 
amount of pus may be absorbed, the pus cells undergoing fatty 



TREATMENT. 523 

degeneration and liquefaction. The operation can be best per- 
formed with the patient etherized, the point selected being a little 
below the lower angle of the scapula. The operation is no more 
difficult than the opening of any deep abscess, and it is not 
dangerous to the patient. The skin being drawn up a little, so 
that after the operation it will close the opening like a valve, an 
incision should be made through the integument, and then a 
medium-size trocar pushed through the walls of the chest into the 
cavity at the upper border of the rib. A trocar of medium size is 
preferable to one that is smaller, as the pus is often thick and would 
flow with difficulty. Or, without the trocar, the operation may 
be performed by the bistoury alone. The admission of a moderate 
amount of air into the pleural cavity in tapping for empyema does 
no harm, except so far as it prevents inflation, since the pleural 
surface with which it comes in contact is already a pyogenic 
membrane. "When the pus ceases to flow, the curved end of a 
pocket male catheter may be introduced, and with the India- 
rubber syringe attached more pus can be removed. I prefer, how- 
ever, to make the aperture sufficiently large, enlarging it a little 
if necessary with a bistoury, that it may remain as a fistulous open- 
ing from which pus continues to flow. The skin acting as a valve 
prevents the admission of air after the canula is withdrawn. If 
the discharge ceases after a day or two, the small quantity of pus 
remaining will commonly be absorbed. The injection daily into 
the pleural cavity, as long as the aperture remains, of a weak 
solution of carbolic acid, of the temperature of the blood, expedites 
recovery, but without this there is a gradual, though sometimes 
slow, convalescence. 

Since the publication of the first edition of this book, thoracen- 
tesis has been performed in four children in my own practice, and 
in one at the Out-door Department at Bellevue. In four the 
apertures was left open, being covered with oakum, and allowed 
to drain, but in three of these pus soon ceased to flow. The five 
children operated on recovered gradually, though four of them 
were in a reduced state which involved immediate danger. In 
about the same period death occurred in nearly an equal number, 
in whom the operation was not performed, in consequence of 
uncertain diagnosis or for other reasons. The one of those operated 
on, in whom thoracentesis was longest deferred, was taken with 
pleuritis of the right side in April, 1871, and the pus was 
evacuated by the knife in September following, the trocar, which 



524 PLEURITIS. 

was introduced immediately afterwards, being of little use, as the 
pus escaped by its side. Although the general health of the child, 
which remained for a time precarious, is fully restored, there are 
evidences of incomplete inflation of the lung. These few cases, if 
they correspond, as I believe they do, with more ample statistics, 
show the urgent need of thoracentesis in the empyema of children, 
and the probability of a favorable result, even when it is performed 
under discouraging circumstances. 

If the liquid removed by the operation prove to be sero-fibrinous, 
it is very important that no air enter the pleural cavity, as it would 
be likely to produce a suppurative inflammation. Therefore, the 
puncture of the walls of the chest should always be made with 
the trocar in those cases in which there is doubt as to the nature 
of the liquid, since the entrance of air can be most readily pre- 
vented when this instrument is employed. In certain cases, in 
which absorption is slow, and empyema is suspected from the 
symptoms, it is proper to ascertain the nature of the liquid by the 
exploring needle before instituting any operative procedure. 



SECTION III. 

DISEASES OF THE DIGESTIVE APPARATUS. 



CHAPTER I. 

SIMPLE STOMATITIS ; ULCEROUS STOMATITIS ; FOLLICULAR 

STOMATITIS. 

Diseases of the digestive system in infancy and childhood are 
of frequent occurrence. They are for the most part readily recog- 
nized, and are more easily and quickly controlled by therapeutic 
agents, if rightly applied, than are the diseases of any other system. 
If misunderstood and improperly treated, they may, even when 
mild and very manageable in their commencement, become chronic 
and obstinate, or even fatal, or they may lead to other and more 
dangerous diseases. It is necessary, then, that the physician should 
understand thoroughly the pathology as well as therapeutics of 
the digestive system, that he may make timely and correct use of 
the required remedies. 

The diseases of the buccal cavity in early life are for the most 
part inflammatory. The mildest is that known as 

Simple or Erythematic Stomatitis. 

This form of inflammation occurs usually before the completion 
of first dentition, and it is most frequent under the age of one 
year. Giving rise in itself to no severe symptoms, and often being 
connected with other grave and dangerous affections, it is, doubt- 
less, in many cases overlooked. It is sometimes confined to a por- 
tion of the buccal surface, or is more intense in one part than in 
another.- In other cases the stomatitis is uniform, or nearly so, 
affecting the entire cavity of the mouth. 

Causes. — The common cause of simple stomatitis in infants is 
the same as that of most cases of gastro-intestinal inflammation 
at that age. This is the use of indigestible and therefore irritating 
food, uncleanliness, personal and domiciliary; in fine, all those 



526 SIMPLE OR ERYTHEMATIC STOMATITIS. 

agencies which impair the general health, and enfeeble the diges- 
tive organs. Therefore, stomatitis, like entero-colitis, is more 
common in the city than in the country, and among the city poor 
than those in the better walks of life. Infants deprived of the 
mother's milk and given a diet which, with all care of preparation, 
is a poor substitute for the natural aliment, are very liable to this 
disease. Beaumont ascertained from his experiments on St. Martin 
that irritative changes produced in the stomach by indigestible 
substances were soon followed by similar changes in* the buccal 
mucous membrane. Since in young infants any kind of artificial 
food is less digestible than the breast milk, it is evident why those 
who are prematurely weaned or are carelessly fed are so liable to 
stomatitis. This inflammation is also sometimes due to irritating 
substances taken in the mouth, as drinks habitually too hot or too 
cold. Stomatitis is also present in measles and scarlet fever. It 
then corresponds with the cutaneous eruption, and disappears 
when that subsides. 

Another cause is dentition. The gum over the advancing tooth 
first becomes inflamed, and, other causes perhaps conspiring, the 
inflammation extends over more or less of the buccal surface. 
When due to dentition the stomatitis is more apt to be partial 
than when it arises from a constitutional cause. Mercury, in 
whatever form introduced into the system, excreted from the 
salivary glands, and flowing over the buccal surface, is an occa- 
sional though now-a-days rare cause. 

Symptoms, Appearances. — Stomatitis, like other mucous inflam- 
mations, is characterized by increased redness and more or less 
thickening of the inflamed buccal membrane, by rapid proliferation 
and exfoliation of epithelial cells, and by an increased functional 
activity of the muciparous follicles. The heat of the mouth is 
sometimes augmented in an appreciable degree. The gums in 
severe cases are swollen and spongy, and bleed easily if rubbed or 
pressed. The tongue is usually covered with a light fur, and the 
salivary secretion is augmented to such an extent sometimes as to 
dribble from the corners of the mouth. Often there is little suffer- 
ing, but in other cases the child is fretful, experiences pain from 
the contact of solid food, and if nursing may even wean itself, 
from dread of pressure of the nipple. 

Simple stomatitis is not diflicult of detection, provided atten- 
tion is directed to the mouth. Inspection informs us of its pre- 
sence and extent. A favorable termination may be confidently 
predicted, unless there is a state of marked cachexia, or a grave 



ULCEROUS STOMATITIS. 527 

coexisting disease. If circumstances are unfavorable, simple 
stomatitis may terminate in a more severe form, as the ulcerous or 
diphtheritic. 

Treatment. — The physician should endeavor to ascertain the 
cause, and, if possible, should remove it by appropriate medicinal 
or hygienic measures. Sometimes no special treatment is required, 
as in measles or scarlet fever. "When the primary affection termi- 
nates, the stomatitis disappears of itself. If dentition is the cause, 
and there is much fever and fretfulness, it may be advisable to 
scarify over the advancing tooth, and employ such soothing and 
derivative measures as are required in painful dentition. In these 
cases mucilaginous and mild astringent lotions may be employed. 
Borax is a good remedy used either with honey or water ; one part 
of borax to three of honey, or a drachm of borax to an ounce of 
water. A weak solution of alum is also -a good topical remedy. 
With either of these remedies in a favorable condition of system, 
and without any serious coexisting disease, the stomatitis is relieved. 

Ulcerous Stomatitis. 

In ulcerous, or, as designated by Rilliet and Barthez, ulcero- 
membranous, stomatitis, the anatomical characters are those of 
severe simple stomatitis, with the additional element which gives 
it the name by which it is designated. 

The inflammation usually begins upon the gums and extends 
along the buccal surface. Wherever it commences, there soon 
appear little white points underneath the mucous membrane, pro- 
ducing slight prominence of it. These points, which are inflam- 
matory exudations mainly fibrinous, gradually enlarge. Some 
unite and give rise to large irregular ulcerations ; others remain 
isolated, producing ulcers which are smaller and of more regular 
shape. There is, indeed, no uniformity as regards the size and 
form of the ulcers. In the folds of the buccal membrane they are 
apt to be elongated, while inside the lips, or where the surface is 
smooth, the circular or oval form predominates. 

Ulcerous stomatitis is usually confined to that part of the buccal 
surface which covers the gums, or is in their immediate vicinity, 
but in some instances it affects nearly every part of the cavity of 
the mouth. 

If the disease is severe, there is considerable swelling around 
the ulcers, but the swollen part is soft and cushiony, and not very 
tender on pressure. The soft and yielding nature of the swelling 



528 ULCEROUS STOMATITIS. 

serves as a means of diagnosis between this disease and the pre- 
monitory stage of gangrene, since in the latter affection the swollen 
part is more indurated. 

If the disease grows worse, more ulcers appear; the fibrinous 
exudation if detached is renewed or it becomes thicker by the 
formation of new layers. The ulcers grow deeper and wider, and 
their edges more vascular. 

If, on the other hand, there is improvement, the swelling sub- 
sides, the ulcers become more clean, their bases approach the level 
of the mucous membrane and present a granulating appearance. 
Finally the mucous membrane is reproduced. A considerable time 
after the ulcers are healed, the new membrane which occupies their 
site has a redder hue than the adjacent surface. 

Causes. — Ulcerous, like simple, stomatitis, is most frequent in 
the families of the poor. Personal uncleanliness, poor food, a 
residence in apartments dirty, humid, or in other respects insalu- 
brious, favor its development. In fine, a cachectic condition, how- 
ever produced, is a common predisposing cause. It frequently 
occurs when the system is reduced or enfeebled by acute diseases, 
as after the essential fevers and thoracic and intestinal inflamma- 
tions. In protracted entero-colitis of infants, it is sometimes severe 
and obstinate, and a case in which this complication arises usually 
ends unfavorably. 

Occasionally several cases occur together or consecutively in 
the wards of a hospital, and this has led some observers to be- 
lieve that ulcerous stomatitis is contagious. But its prevalence 
under such circumstances is attributable to the fact that there is a 
common exposure to the influences which give rise to the disease, 
just as a whole household exposed to malaria may be seized with 
intermittent fever. Difficult dentition is also an occasional cause. 

Symptoms. — The symptoms in ulcerous stomatitis are more severe 
than in the simple form. There is more fever, more salivation, 
and more fretfulness. The ulcerated surface is sometimes very 
tender, so that there is but little sleep. Drinks, unless bland and 
lukewarm, are painful, and, if the ulcers are on the lips or the front 
of the mouth, the infant nurses less eagerly than usual, and even 
with reluctance, sometimes weaning itself. Occasionally the sub- 
maxillary glands are tumefied, hard, and tender. The breath has 
an offensive odor. In mild cases in which the stomatitis is of 
limited extent, this odor may scarcely be noticed, but in severe 
cases it is almost like that exhaled from putrid substances. 



PROGNOSIS — TREATMENT. 529 

Prognosis. — A favorable prognosis may be given unless the 
patient is in a decidedly cachectic condition, or there is a serious 
coexisting disease, under which circumstances the case may be 
protracted. If death occur, it is due to the cachexia or to some 
pathological state quite distinct from the stomatitis, most fre- 
quently entero-colitis. Ulcerous stomatitis, when the ulcers are 
small and the inflammation of limited extent, is of course more 
easily cured than when it is extensive and the ulcers are large. 

This disease is very liable to return, unless the general health is 
good. 

Treatment. — The physician should endeavor to ascertain the 
cause of the stomatitis, and so far as possible should remove the 
patient from its influence. It is often necessary, in order to insure 
a speedy recovery, to recommend a change in regimen, especially 
as regards diet and cleanliness. If the patient live in damp, dark, 
and dirty apartments, the family should seek a better residence, 
and he should be taken daily in the open air. 

Tonic remedies are generally required. The ferruginous pre- 
parations may be advantageously given, or the vegetable tonics, 
or the two in combination. In selecting the internal remedies we 
must regard the antecedent disease, if there be any, which the 
buccal inflammation complicates, and on which it depends. For 
that large proportion of cases in which there is chronic intestinal 
inflammation, the liquor ferri nitratis with tincture of columbo 
administered in simple syrup will be found useful. For local 
treatment Trousseau recommends occasional applications of nitrate 
of silver or muriatic acid as a caustic, and in the intervals a wash 
of equal parts of borax and honey. 

The chloride of lime is also considerably used in Paris. It is re- 
commended by Eilliet and Barthez. It is applied dry to the ulce- 
rated surface twice daily, and in the interval the mouth is washed 
with simple water. This treatment is continued till the ulcers 
present a healthy appearance and begin to cicatrize. Then a weak 
solution of chloride of lime is employed, one grain to forty-five of 
the vehicle. By this treatment a cure is usually effected. Bouchut 
prefers using chloride of lime with honey, one drachm to the 
ounce. 

But painful applications are not required. The remedy which 
is most employed in this country and in Great Britain is chlorate 
of potash. It often acts like a specific for this as well as other 
forms of stomatitis. It may be given dissolved in water with 
sugar, or with one of the syrups to render it more palatable. The 
34 



530 FOLLICULAR STOMATITIS. 

dose is from two to five grains every two hours. It should be 
allowed to run over the affected part, as it is believed to have a 
local action. 

I£. Potass. Chlorat. 5j ; 
Mellis Jss; 
Aquse |ij. 
One teaspoonful every two or three hours. 

Of all topical remedies in common use, chlorate of potash is the 
most safe, most easily administered, least painful, and probably 
the most efficacious. Some physicians prefer the chlorate of soda, 
on account of its greater solubility. 

Follicular Stomatitis. 

In this form of stomatitis the inflammation is confined to the 
muciparous follicles of the mouth, or to them and the mucous 
membrane in their immediate neighborhood. 

Anatomical Characters. — At first there appear in the mouth 
minute papular elevations, red, hard, and tender, which continue 
to enlarge and soon become vesicular. They may now break, 
leaving an ulcerated surface ; but if they continue entire they be- 
come purulent, and then their contents are discharged. From the 
commencement of the papule to the purulent transformation the 
period is perhaps three or four days. 

The ulcer which occupies the site of the eruption is round, hard, 
painful, and with a vascular margin. The base has a white or 
grayish appearance. The reparative process soon commences, the 
ulcer presents a healthy appearance, its size is gradually dimin- 
ished, and finally cicatrization occurs. 

The liquid with which the follicles are distended in the first 
stages of the disease is believed to be the natural secretion some- 
what modified by the inflammation. 

The number of ulcers is various. There are in most cases from 
six or eight to as many as twenty. They are ordinarily discrete, 
and one or two lines in diameter. The stages of the disease rapidly 
succeed each other, and the patient fully recovers in from six to 
eight days, but not always. In exceptional instances the ulcers 
enlarge and become confluent, or one or more of them assume 
a gangrenous appearance. This indicates a faulty condition of the 
system, a vitiated state of the blood, due perhaps to some antece- 
dent or concomitant disease. In these cases the ulcerative stage is 
apt to be protracted, and recovery doubtful. 



CAUSES— SYMPTOMS. 531 

The seat of follicular stomatitis is usually the internal surface of 
the lips and cheeks, the gums, tongue, and occasionally the roof 
of the mouth. It rarely affects the fauces. Occasionally this form 
of stomatitis is associated with more general inflammation of the 
buccal cavity. The gums may then be swollen and tender, bleed- 
ing if rubbed or pressed. 

Causes. — The causes are not fully ascertained. Follicular 
stomatitis has not usually in my practice occurred in so feeble a 
state of system as has been present in ulcerous stomatitis. Billard, 
speaking of the aphthse, or ulcers of this disease, says : " They are 
particularly to be seen in children who are very feeble, pale, and 
of a lymphatic temperament. We do not look for the causes of 
aphthse in the retention of the meconium, acidity of the milk, or 
in the predominance of acidity in the fluids of the child; we 
attach more importance to the consideration of the original pre- 
dominance of the lymphatic system, or rather to the remarkable 
predominance which this system acquires under the influence of 
bad nutrition and vitiated air which is respired in badly ventilated 
places in those who are crowded together with a number of sick 
children." 

Barrier considers follicular stomatitis to be allied to those gas- 
trointestinal diseases which are attended by turgescence of the 
mucous follicles, and he mentions among the causes habitual con- 
gestion of the buccal mucous membrane, and difficult dentition. 
In most cases probably the exciting cause is some derangement 
of the digestive organs which may not be appreciable. 

While simple stomatitis, and stomatitis with thrush, are most 
common under the age of six months, follicular stomatitis is rare 
at this age. It is most frequent during the time which corresponds 
with dentition, when there is also the most rapid development and 
greatest activity of the muciparous follicles. 

Symptoms. — The constitutional symptoms in a large proportion 
of cases of aphthse are slight. In twelve children affected with 
this disease Billard found the pulse from sixty to eighty beats per 
minute. 

The ulcers are painful, as is indicated by the cries of the child 
when they are pressed, and its fretfulness. Solid food, and even 
drinks unless bland and unirritating, are badly tolerated. The 
salivary secretion is also augmented. 

In those rare cases in which the ulcer becomes confluent or 
gangrenous, the state of the patient is really serious. There is 
then often gastro-intestinal disease. The symptoms indicate pros- 



532 FOLLICULAR STOMATITIS. 

tration. The pulse is feeble, the countenance pallid, and the body 
and limbs become wasted. 

Diagnosis. — This is easy. The only disease with which it is 
liable to be confounded is ulcerous stomatitis. In the ulcerous 
form there is antecedent and accompanying stomatitis affecting a 
considerable part, if not the entire buccal cavity, while in the 
follicular form the inflammation is ordinarily confined to the im- 
mediate vicinity of the ulcers. The character of the ulcers serves 
also as a means of distinction. In ulcerous stomatitis there is 
great variety as to size and form, while in follicular stomatitis 
there is great uniformity in both these respects. The small, cir- 
cular ulcers are characteristic of the follicular inflammation. 
Before the ulcerative stage the vesicular eruption serves to distin- 
guish this form of stomatitis from other local diseases affecting 
the cavity of the mouth. 

Prognosis. — Follicular stomatitis usually ends favorably ; but, if 
the ulcers become concrete or gangrenous, the health is seriously 
affected, and a more cautious prognosis should be expressed. The 
unhealthy appearance of the mouth, and the real danger, are often 
more due to the depressing effect of some concomitant disease than 
to the stomatitis. 

Treatment. — In ordinary follicular stomatitis, which is dis- 
crete and attended by little or no constitutional disturbance, local 
remedies suffice to cure the disease. Demulcent drinks, or appli- 
cations to the mouth, should be used, as the mucilage from gum 
acacia, marsh-mallow, or flaxseed. Mild astringent lotions with 
the demulcent are also beneficial. The mel boracis is one of the 
best and most agreeable applications. It may be placed in the 
mouth with a spoon, or applied with a camel-hair pencil. If there 
is much tenderness of the ulcers, with restlessness, a small quantity 
of some opiate should be added to the lotion, or it may be admin- 
istered separately. 

"With this simple treatment the ulcers generally soon heal, and 
the health of the patient is restored. If, however, the ulcers are 
quite painful, and not disposed to heal, or are healing tardily, 
they may be touched lightly with a pencil of nitrate of silver, or, 
as Barrier recommends, hydrochloric acid in honey of roses. This 
diminishes the tenderness and expedites the healing process. 

If, as may in rare cases occur, the ulcerations are numerous, 
and are accompanied by considerable fever, there may be symp- 
toms indicative of cerebral congestion, or even premonitory of 
convulsions. In such cases laxative and diaphoretic remedies are 



THRUSH — ANATOMICAL CHARACTERS. 533 

required, and sinapisms or other revulsive applications to the ex- 
tremities. 

If there is an unhealthy appearance of the ulcers, if they gradu- 
ally enlarge, or become concrete, or gangrenous, indicating a 
cachectic state, tonics should he employed with nutritious and 
easily digested diet, and anti-hygienic influences should so far as 
possible be removed. 



CHAPTEE II 

THRUSH. 



The terms- thrush, sprue, and muguet, the last from the French, 
are synonymous. They are used to designate a particular form 
of inflammation of the digestive apparatus, the peculiar feature of 
which is the presence of points or patches of a curd-like appear- 
ance on the inflamed surface. 

The usual seat of thrush is the mucous membrane of the mouth, 
but occasionally it affects the fauces, pharynx, and oesophagus. It 
is very rare in the sub-diaphragmatic portion of the digestive tube, 
but a few such cases have been reported by Billard and others. It 
never affects the membrane of the nostrils, larynx, or bronchial 
tubes, and it very seldom occurs in any other part of the alimentary 
canal without also being present in the mouth. Thrush, then, is 
a stomatitis, pharyngitis, or oesophagitis, or a gastro-enteritis, with 
the additional element which I have described. 

Anatomical Characters. — The first stage of thrush is that of 
simple inflammation of. the mucous surface. There next appear 
minute semi-transparent points or granules, which, increasing, 
soon become white and opaque. Some of them remain as points, 
while others, extending, and perhaps coalescing with those adjoin- 
ing, form patches of greater or less extent. The white points or 
patches are unequally elevated. Their central part, which was 
first formed, is most raised, while their circumference projects but 
little above the epithelium. Their highest elevation is not ordi- 
narily more than a line above the surface. They are smaller in 
the pharynx and oesophagus than when occurring upon the buccal 
surface. They resemble closely, in color and consistence, portions 
of curdled milk, and the nurse often mistakes them for such, and 
neglects to call attention to the state of the mouth. They are 



534: THRUSH. 

readily detached by a little force, but are speedily reproduced. 
Their color in the first days of the complaint is white, and some- 
times this color continues. In other cases they assume, if the dis- 
ease is protracted, a yellow hue. 

Their true nature, long unknown, was finally revealed by 
microscopy. They consist in part of epithelial cells, and in part 
of a vegetable growth. This parasitic plant is in most cases the 
oidium albicans. Like other confervas, it consists of roots, branches, 
and sporules. The roots are transparent, and they penetrate the 
epithelial layer, sometimes even to the basement membrane. The 
branches divide and subdivide at an acute angle, and under the 
microscope they are seen to consist of elongated cells, with one or 
two nuclei. Around these branches are numerous sporules. In 
two or three instances I have examined the product of thrush 
removed from the oesophagus, and in both the parasitic plant was 
the penicillium glaucum, or a conferva closely resembling it. 

In the mildest form of thrush, this morbid product is in points 
or small patches. If the patches are of large extent, especially if, 
as rarely happens, a considerable part of the buccal surface is 
covered by them, there is generally a state of great prostration and 
danger, from some antecedent or concomitant disease. Thrush is, 
indeed, often the sequel of some grave affection, as pneumonitis 
or gastro-intestinal inflammation. Its complication with the last 
named disease is common in young, ill-fed infants, especially those 
deprived of the breast milk, and such cases are very apt to be 
fatal. 

Hence, some writers, who have studied infantile diseases in 
foundling hospitals, regard thrush as one- of the most serious affec- 
tions of early life. Valleix, in a book of seven hundred pages re- 
lating to diseases of children, devotes more than one-third to the 
consideration of muguet. Of twenty-four cases, the records of 
which he publishes, twenty-two died, but their death was due to 
gastro-intestinal inflammation, which the author considered a part 
of the more general disease, muguet. Doubtless the same cause 
which produced the stomatitis, with the confervoid growth, in 
these infants, also produced the fatal gastritis or gastro-enteritis, 
occurring without this growth upon the gastric or intestinal sur- 
face. It seems to me much better to restrict the term sprue, thrush, 
or muguet to the inflammation of that portion of the mucous sur- 
face which is the seat of the parasitic growth. I reject, then, from 
my description of the anatomical characters of thrush, those sub- 
diaphragmatic inflammations which some writers consider an im- 



SYMPTOMS — CAUSES. 535 

portant part of this disease, and place them in the list of coexisting 
affections. When the fatal gastric or intestinal inflammation is 
accompanied by the characteristic vegetable growth on the gastric 
or intestinal surface, it is proper in my opinion then, and only then, 
to say that death occurred from thrush. This explanation seems 
necessary in order to understand the different statements of writers 
in relation, not only to the anatomical characters of thrush, but 
also in reference to its mortality. 

The frequent coexistence of thrush with gastro-intestinal inflam- 
mation, has been remarked in the hospitals of Europe, and in the 
Infant Asylum and the Child's Hospital, in this city. In the post- 
mortem examinations of those who have died in these last institu- 
tions, having thrush at the time of death or immediately prior to 
it, and who for the most part have been infants under the age of 
three months, I have frequently found evidences of inflammation 
in every division of the alimentary canal. The confervoid growth 
was, however, seldom found below the fauces, and never below the 
oesophagus. 

Symptoms. — The symptoms in thrush are not different in most 
cases from those of simple inflammation. In the mildest cases 
they are chiefly of a local nature, such as have already been de- 
scribed in our remarks on simple stomatitis. If the inflammation 
is more extensive, especially if it affect the fauces and oesophagus, 
the infant becomes feverish and fretful, and the inflamed surface 
is hot, red, and tender. In the worst forms of thrush this surface 
not only presents the ordinary features of severe inflammation, 
namely heat, redness, and tenderness, but it is sometimes deficient 
in the natural secretion, so as to present a dry or parched appear- 
ance. It is in these cases that there is often a more extensive in- 
flammation than that of the buccal or oesophageal membrane. The 
sub-diaphragmatic portion of the digestive tube is inflamed. The 
infant in these severe cases has thirst, loss of appetite, restlessness, 
vomiting, and frequently diarrhoea. The countenance is anxious 
and pale ; there is rapid emaciation, and, if the disease is not ar- 
rested, a state of extreme prostration soon occurs. The twenty-four 
severe cases related by Valleix, already alluded to, twenty-two 
of which were fatal, were examples of this severe form. 

Causes. — Thrush is most apt to occur in those who are consti- 
tutionally feeble, or who are enfeebled by disease, or by unfavor- 
able hygienic conditions. Cachexia is a cause common to thrush 
and most other subacute inflammations of the alimentary canal. 
The most obvious and common of the unfavorable hygienic con- 



536 THRUSH. 

clitions alluded to is the continued use of indigestible and im- 
proper food. It is, therefore, a common disease among foundlings, 
in institutions where these unfortunates are received, since they 
not only breathe an atmosphere which is often impure, but are 
deprived of the mother's milk, and are so frequently given a diet 
which is a poor substitute for it. Among the poor of the cities 
thrush is common, since with them, from necessity or choice, there 
is the greatest neglect of sanitary requirements. Exposure to hu- 
midity, to variations in temperature, increases the liability to the 
disease, though in less degree than defective alimentation. Billard 
and Valleix agree that thrush is more frequent in the warm months 
than in the cold, that its maximum frequency is in the months of 
July, August, and September. Cases in the Infant Asylum and 
Child's Hospital, of this city, have appeared to me to correspond in 
this respect with those related by Billard and Valleix. Various 
writers have mentioned the age at which thrush is most apt to 
occur, as one of the predisposing causes. Thrush is not common 
above the age of six months, and a majority of the cases occur under 
the age of three months. Infants of the age of one or two weeks, 
if in addition to lactation they are spoon-fed by nurses over- 
anxious that they should thrive, are apt to take the disease. 

Diagnosis. — This is easy so far as thrush in the mouth is con- 
cerned, for simple inspection by one familiar with the disease is 
all that is required in order to discover it. The presence of thrush 
in portions of the alimentary canal hidden from view cannot be 
positively ascertained. 

The vomiting, diarrhoea, pain or fretfulness, emaciation, and 
rapid sinking, which sometimes accompany severe forms of thrush, 
indicate gastro-intestinal inflammation, to which the attention of 
the practitioner should be chiefly directed. 

Prognosis. — The duration of thrush varies according to its 
intensity, and the favorable or unfavorable condition of the child. 
If it is slight and the health of the infant otherwise good, it may 
often be cured in two or three days. Under other circumstances 
it may continue as many weeks or even longer, before it is entirely 
removed. 

When thrush occurs in connection with gastro-enteritis, the 
mortality is very great. It has been already stated that in Val- 
leix's twenty-four cases twenty-two were fatal. M. Auvity esti- 
mates the mortality of such cases at nine in ten, and M. Godinat 
at two in three. 

Treatment. — As one of the most common causes of thrush is 
the use of indigestible or improper food, the physician should 



TREATMENT. 537 

ascertain the nature of the infant's diet, and if it is faulty should 
direct a better. In many cases the infant is bottle-fed. It should 
be given only the mother's milk if practicable, or that of a healthy 
wet-nurse. This change of alimentation often removes the sole 
cause of thrush in the young infant, so that it rapidly recovers. 

If artificial feeding is necessary, such diet should be advised as 
is directed in our remarks on the treatment of the diarrhceal 
maladies. There is often in thrush an excess of acidity in the 
digestive tube, and an alkali is required. Trousseau recommends 
the addition of saccharate of lime to the milk. Children with 
this disease should also be taken from filthy and damp apartments, 
to those in which the air is pure and dry. 

The remedy in common use in the treatment of thrush, and 
which is usually effectual, is borax. This, if applied sufficiently 
often to the affected membrane, not only destroys the parasitic 
growth, but prevents its reproduction. It is commonly employed 
with honey, or in a powder with sugar or dissolved in water. The 
officinal mel boracis, consisting of one part of borax to eight of 
honey, is so much used in families that it may be considered almost 
a domestic remedy. There is, however, an objection to using any 
application for the removal of thrush which contains either sugar 
or honey, since either substance remaining in the mouth would 
rather promote the growth of the parasite. Still, it is desirable to 
employ a wash of such consistence that it will remain a longer time 
in contact with the buccal surface than will a simple solution in 
water. I know no better vehicle for the borax than glycerine, 
which has the advantage of consistence, does not readily undergo 
any chemical change, and has no unpleasant flavor. The borax 
may be used dissolved in glycerine, with or without some flavoring 
ingredient : — 

fy. Sodse borat. 5j ; 
Glycerinse 3ij ; 
Aquae 3vj. Misce. 

Borax should be used four or five times daily, and continued 
for a time after the disease has disappeared from sight, since the 
roots of the plant must be destroyed or the branches are rapidly 
reproduced. It should be applied by a camel-hair pencil, or with 
a soft cloth upon the finger or a stick. It should be so freely 
used, in extensive and severe forms of the disease, that the infant 
will swallow some, as the entire oesophagus is apt to be affected in 
such cases. In the intervals between the applications of borax, 
if the buccal surface is hot, dry, and tender, so as to increase the 



538 GANGRENE OF THE MOUTH. 

fretfulness of the infant, it is well to use mucilaginous washes, as 
the mucilage of acacia or mallows. If the disease continue not- 
withstanding the use of these measures, the mouth should be 
occasionally washed with a weak solution of nitrate of silver or 
sulphate of zinc : — 

I£. Zinci sulph. gr. ii-iv ; 
Aq. Kosse ^ij. Misce. 

In many cases, however, the treatment of thrush is of less im- 
portance than that of the disease which the thrush complicates. 
The remedial measures which I have mentioned then become 
subordinate to those employed for the graver disease. When this 
disease is relieved and the general health improves, thrush is more 
easily and permanently cured than during the state of feebleness 
and ill-health. 



CHAPTER III. 

GANGRENE OF THE MOUTH. 

The diseases of the mouth which we have been considering are 
attended by little danger, but the one which we are next to con- 
sider is among the most fatal affections of early life. It is gan- 
grene of a portion of the cheek or gums, or of both. It is described 
by writers under various names, as cancrum oris, noma, necrosis 
infantilis, aqueous cancer of infants. 

Anatomical Characters. — Gangrene of the mouth is sometimes 
preceded by ulceration of the mucous membrane, at the point 
where it is about to commence, but in other cases this membrane 
is entire. The tissues at the point of attack, which is most fre- 
quently the inside of the cheek, become inflamed, thickened, and 
indurated. The induration extends, and soon the purple hue of 
gangrene appears and increases. The next stage in the' progress 
of gangrene is sloughing of the portion the vitality of which is 
lost. 

The slough does not present the appearance of uniform decay. 
While the color is generally dark, there are in the mass fibres of 
connective tissue or even bloodvessels, which remain unchanged 
or are but partially decomposed. After separation or sloughing 
of the part where the vitality is first lost, the surface of the 



AGE. 539 

excavation, if the disease is not checked, has a dark, jagged, and 
unhealthy appearance. Commencing with the mucous membrane 
and the tissue immediately underlying it, the disease extends on 
the one side towards the skin, and on the other towards the 
deeper seated structures of the jaw. According to Billard, the 
swelling which precedes and surrounds the gangrene is in great 
part cedematous. 

This disease is occasionally primary, but in a large proportion 
of cases it is secondary. Occurring secondarily, its symptoms are 
often masked by those of the antecedent and coexisting affection. 
Under such circumstances attention is sometimes first directed to 
the mouth, by the loosening of one or more of the teeth, or the 
appearance on the skin of a livid circular spot, which indicates 
the approach of the disease to the cutaneous surface. The mucous 
membrane presents a dark red appearance to the distance of a few 
lines beyond the point of gangrene. It covers tissues which are 
inflamed and indurated and about to become gangrenous. 

The tongue is usually more or less swollen, unless the disease 
is mild ; an offensive odor arises from the gangrene, due to the 
evolution of sulphuretted hydrogen and other gases. There is 
great difference in the extent of the destruction, and the gravity 
of the disease, in different cases. It may sometimes be arrested by 
proper applications and a favorable change in the general health of 
the child at an early period, when there is little loss of substance. 
In other cases it extends till it perforates the cheek, or even 
destroys a considerable part of the side of the face, and, extending 
inwards, attacks the periosteum of the maxillary bone, destroying 
the gum and teeth, and denuding the alveoli. Recovery, if it take 
place at all under such circumstances, is with the loss of a portion 
of the bone, and with deformity. 

The duct of Steno is sometimes included in the gangrenous por- 
tion, but it commonly resists the destructive process, and remains 
pervious. 

Age. — The age at which gangrene of the mouth occurs is usually 
between two and six years. In twenty-nine cases collated by 
Eilliet and Barthez, twenty-one were between the ages of two and 
six years, and the remaining eight were from six to twelve years 
old. Of the cases which have fallen under my observation, all 
were between the ages of two and six years. It is seen that the 
period of greatest frequency of gangrene of the mouth is different 
from that at which the ordinary forms of stomatitis occur. 

Gangrene of the mouth may, however, occur under the age of 



540 GANGRENE OF THE MOUTH. 

one year. Billard reported three cases under the age of one month, 
but in two of these the disease does not appear to have been 
sufficiently marked to render it certain that they were genuine 
cases of this affection. 

Causes. — Gangrene of the mouth usually occurs" in those whose 
systems are reduced or cachectic. It is, therefore, more frequent 
among the poor than those in comfortable circumstances ; in the 
city than in the country. It is more frequently observed in 
asylums for children than in private practice. Half the cases 
which I have seen have been in these institutions. If the consti- 
tution is naturally good, it can only occur in those long deprived of 
pure air and wholesome nutriment, or those enfeebled by disease. 

Among the diseases which have been known to terminate in or 
be followed by gangrene of the mouth, are the pulmonary and 
intestinal inflammations, hooping-cough, and the fevers, both 
eruptive and the non-eruptive. Rilliet and Barthez have pub-' 
lished a table of ninety-eight cases in which gangrene resulted 
from other diseases. In forty-one of these the antecedent disease 
was measles, in five scarlet fever, six hooping-cough, nine inter- 
mittent fever, nine typhoid fever, seven mercurial salivation, and 
five enteritis. It is seen that the essential fevers were the most 
frequent cause of the gangrene. Of forty-six cases collected by 
MM. Bouley and Caillault, the antecedent disease was measles in 
all but five. In this city, also, a larger number occur from measles 
than from any other disease. 

One reason why so many cases of gangrene occur as a sequel 
of measles is probably because this disease is accompanied by 
stomatitis. Simple or ulcerous stomatitis often precedes gangrene. 

Diseases sometimes terminate in gangrene of the mouth chiefly 
in consequence of injudicious treatment, which has lowered the 
vitality of the system. Rilliet and Barthez mention the case of a 
child four years old, in whom gangrene commenced at the twenty- 
ninth day of primitive pneumonia. This child had been reduced 
by the application of twelve leeches, three scarifications, a large 
blister, and by the use of absolute diet. 

The misuse of mercury was once a much more frequent cause 
of gangrene than at present, at least in this country, since this 
agent was formerly much more employed than now. In fact most 
of the affections of infancy and childhood in which mercurials 
were formerly employed are now treated without it. 

Symptoms. — Gangrene of the mouth so often occurs in connec- 
tion with other disease, that its symptoms are in a large propor- 



SYMPTOMS, 



541 



tion of cases blended with those which arise from a distinct 
pathological state. 

There is usually prostration more and more pronounced as the 
gangrene extends. The features are ordinarily pallid, but occa- 
sionally their normal color is preserved for a time ; the expression 
of the face is melancholy but composed. Sometimes the child is 
fretful, if disturbed ; at other times it will quietly consent to an 
examination. The suffering is not proportionate to the gravity of 
the disease. There is less pain often than in some of the forms of 
stomatitis which are unattended with danger. 

As the disease advances, the body and limbs gradually waste, 
the eyes are hollow, or, if the gangrene is near the orbit, the eye- 
lids become cedematous, the lips are infiltrated, and both the lips 
and nostrils are often incrusted. If the cheek is perforated, 
alimentation is rendered more difficult, and the appearance of the 
child is melancholy in the extreme. 




The tongue is usually moist; it is occasionally swollen. The 
saliva flows from the mouth, either pure or mixed with offensive 
sanguinolent matter. Unless the disease is slight, there is the 
peculiar gangrenous odor. The appetite is sometimes poor, at 
other times it is preserved through the whole sickness. There is 
no vomiting or looseness of the bowels, unless from a complication. 



542 GANGRENE OF THE MOUTH. 

The thirst is usually great, and the pulse is accelerated and feeble, 
except in mild cases. 

The skin in the commencement of gangrene is hot. When 
the vital force is much reduced, and especially as the disease 
approaches a fatal termination, the face and limbs become cool, 
and the surface generally presents a waxen or ashy appearance. 
There is no derangement of the respiratory system. Those cases 
which are attended by a cough or accelerated respiration are 
really cases of bronchitis or pneumonitis, coexisting with the gan- 
grene. 

Diagnosis. — Gangrene of the mouth is easily diagnosticated. 
In those cases in which ulceration precedes the gangrene, it might 
be mistaken in its first stages for that form of ulcerous stomatitis 
in which the ulcers assume an unhealthy appearance. The follow- 
ing are the distinguishing features of the two affections: Around 
the ulcer where gangrene is about to commence, the tissues are 
greatly thickened and indurated, or oedematous, while ulcerous 
stomatitis begins with a submucous deposit of fibrin, and is attend- 
ed by little thickening of the surrounding parts, and little or 
no induration or oedema. In ulcerous stomatitis, the skin over 
the seat of the disease presents its normal appearance, whereas in 
gangrene it presents a distended and shining appearance. The 
destructive process in ulcerous stomatitis is also more limited than 
in gangrene. Deep ulcerations do not occur, or are rare. Ulcerous 
stomatitis is more readily healed, and it leaves no eschar, contrac- 
tion, or deformity. 

The differential diagnosis of gangrene of the mouth, from those 
cases of follicular stomatitis in which the ulcers occupying the seat 
of the follicles assume a gangrenous appearance, must be made by 
a consideration of the same facts or particulars which serve to dis- 
tinguish it from ulcerous stomatitis. 

Malignant pustule, of rare occurrence in the child, resembles 
this disease in some of its features. But the pustule always begins 
on the skin, while gangrene is a disease of the mucous surface 
primarily. In gangrene, therefore, the chief destruction is of the 
mucous membrane and of the submucous tissue, while in malignant 
pustule the chief destruction is of the skin and the subcutaneous 
tissue. 

Prognosis. — This depends, not only on the extent of the gangrene, 
but the nature of the disease, if there be one, which gave rise to it, 
and the degree of cachexia. If it occurs in connection with or as 
a sequel of one of the least debilitating diseases, and there is con- 



PKOGNOSIS. 543 

siderable vigor of system, it may often be arrested when it has 
destroyed only the mucous and subcutaneous tissues, so that no de- 
formity results. The friends may congratulate themselves if the 
case terminate so favorably. In the graver cases, when the gan- 
grene extends till it destroys the periosteum of the maxillary bone 
on the affected side, and perhaps perforates the cheek, if the child 
recovers it is with the permanent loss of teeth, tedious separation 
of the necrosed bone, and a cicatrix, which is apt to interfere with 
the free use of the jaw. Death is, however, the more common 
termination of severe cases. Occasionally the gangrene destroys 
the continuity of a bloodvessel, causing abundant hemorrhage, and 
accelerating the fatal result. In most cases, however, there is little 
or no hemorrhage, in consequence of coagulation in the vessels. 

Another serious complication occasionally arises, namely, gan- 
grene of other parts, as of the external genital organs. The English 
editor of Bouchut's treatise on diseases of children, relates the fol- 
lowing interesting case, from the Transactions of the Edin. Meclico- 
Chir. Society : — 

An infant eight months old became affected with gangrene of 
the face, head, and hands. " The right ear aud the entire hairy 
scalp were of an intensely black color, and on both cheeks patches 
existed about the size of a half-crown piece. The right thumb 
and the backs of both hands were similarly affected. The child 
was noted to have been restless and feverish on May 22d, and on 
the 23d a slightly darkened ring was found to have formed round 
the thumb, about the middle of the first phalanx ; in a few hours 
the whole thumb was gangrenous, and the dorsum of the hand be- 
came involved. On the ear the gangrene commenced with the 
appearance of a fleabite, and subsequently extended rapidly to the 
scalp, assuming a remarkably regular form, and giving to the child 
the appearance of wearing a black skullcap. The pulse was ob- 
served to be very feeble. * * * Death took place in twelve 
hours from the first appearance of gangrene on the thumb, the 
child being sensible and continuing to suck well, up to a few 
minutes before death." 

Rilliet and Barthez state that pneumonitis is apt to arise in the 
course of gangrene of the mouth. Such a complication evidently 
diminishes materially the chance of recovery. 

Whether the result be favorable or unfavorable, it is evident, 
from the nature of the disease, that the duration is very different 
in different cases. The physician's attendance may be required for 
a week or two or for several weeks. 



544 GANGRENE OF THE MOUTH. 

Treatment. — As gangrene of the mouth is eminently a disease 
of debility, all anti-hygienic influences should be removed, and the 
most nourishing diet, together with tonics, be recommended. The 
ferruginous preparations or the bitter vegetables are required. 

As soon as the physician is called, he should endeavor to arrest 
the gangrene, accelerate the detachment of the slough, and pro- 
duce a healthy and granulating state of the surrounding tissues. 
This is best effected by applying a highly stimulating or even 
escharotic agent to the inflamed surface underneath and around 
the gangrene. For this purpose a great variety of substances 
have been used by different physicians, such as acetic, sulphuric, 
nitric, and hydrochloric acids, nitrate of silver, the acid nitrate of 
mercury, chloride of antimony, and even the actual cautery. 
s M. Taupin recommends, after removing a considerable part of 
the gangrenous substance with scissors or some instrument, the 
application of strong muriatic acid, and, when the slough is de- 
tached, of dry chloride of lime. 

Eilliet and Barthez advised the use twice daily of muriatic acid 
or the acid nitrate of mercury, applied by a brush upon and 
around the slough, followed immediately by the application of 
dry chloride of lime, when the mouth is to be thoroughly washed 
with water from a syringe. They direct in the interval frequent 
ablution with water. After the slough has separated, the escharotic 
is to be discontinued, and the chloride of lime used alone. If 
gangrene extends to the skin, a crucial incision is to be made and 
the escharotic applied, after which powdered cinchona is intro- 
duced and retained by a plaster. This treatment is to be continued 
till the gangrene is arrested and the decayed portion removed. 
Barrier, Yalleix, and most French writers, recommend essentially 
the same treatment, namely, the application of undiluted escharotic 
agents. 

A safer, less painful, and, in my opinion, preferable, treatment, 
is that employed by many British and American physicians, 
namely, the use of escharotic agents diluted, or, if applied in their 
full strength, such as are least active and penetrating. Some 
employ from the first topical treatment which is astringent and 
stimulating rather than escharotic, and they report satisfactory 
results. 

Dr. Gerhard believes " the best local applications are the nitrate 
of silver, if the slough be small in extent ; if much larger, the 
best escharotic is the muriated tincture of iron, applied in the 
undiluted state. After the progress of the disease is arrested, the 



TREATMENT. 545 

ulcer will improve rapidly under an astringent stimulant, such as 
the tincture of myrrh, or -the aromatic wine of the French Phar- 
macopoeia." 

The local treatment recommended by Evanson and Maunsell I 
believe to be preferable to that advised by any of the writers from 
whom I have quoted. I have seen it so successful, that I should 
employ it in all ordinary cases from the first visit. A knowledge 
of this treatment will be best imparted by quoting from the 
authors (Diseases of Children, 2d Amer. edit., page 188): "The 
lotion which we have found by far the most successful is a solu- 
tion of sulphate of copper as employed by Coates in the Children's 
Asylum. His formula is as follows: — 

"^. Cupri sulpli. 5ij ; 

Pulv. cinchoiiEe gss ; 
Aquae ^iv. M. 

"This is to be applied twice a day very carefully to the full 
extent of the ulcerations and excoriations. The addition of the 
cinchonse is only useful by retaining the sulphate of copper longer 
in contact with the edges of the gums. A solution of the sulphate 
of zinc, 3j to an ounce of water, by itself or combined with tinc- 
ture of myrrh, Dr. Coates found to be also useful in some cases." 

A moment's reflection will show us that the above treatment is 
far preferable, provided it is equally effectual in arresting the gan- 
grene, to the treatment by the strong escharotics which some of 
our best practitioners employ. 

Take, for example, the use of pure nitric or muriatic acid, which 
physicians of experience recommend. This agent causes such pain 
that it occasions restlessness of the child, and such stout resistance 
that the use of chloroform has been recommended to facilitate its 
application. The pain occurring from it and from the inflamma- 
tion which it excites doubtless reduces the strength which it is 
very necessary to preserve. If the acid comes in contact with the 
teeth, as it generally will, it injures them irreparably, and it some- 
times attacks the jaw-bone. Dr. West, who advocates the use of 
the acid (Diseases of Infancy and Childhood, 4th Amer. edit., page 
467), says: "In one of the cases that I saw recover, the arrest of 
the disease appeared to be entirely owing to this agent, though the 
alveolar processes of the left side of the lower jaw from the first 
molar tooth backwards died and exfoliated, apparently from having 
been destroyed by the acid." No such result follows the use of the 
solution of sulphate of copper, and of its efficacy I can speak con- 
35 



546 DENTITION. 

fidently. In one of those severe eases in which the disease resulted 
from scarlet fever, and in which there was so much debility that 
an unfavorable prognosis was made, I succeeded in arresting the 
disease by the use of Dr. Coates' prescription. The child recovered 
with the loss of two teeth, and the corresponding portion of the 
maxillary bone. 

The application should be made twice a day till the gangrene 
is arrested, and healthy granulations appear. 

The gases arising from the gangrenous mass are not only highly 
offensive to others, but they are doubtless injurious to the patient, 
who is constantly inhaling them. To remove the fetor chlorine or 
carbolic acid properly diluted should be occasionally used between 
the applications of the sulphate of copper. Labarraque's solution, 
one part to eight or ten parts of water, is an eligible form for its 
use. When the gangrene is removed, and the granulations present 
a healthy appearance, all danger is usually past, and convalescence 
is fully established. Then no energetic topical treatment is re- 
quired. A mild stimulating lotion, like the tincture of myrrh, as 
recommended by Dr. Gerhard, suffices with the aid of tonics and 
nutritious diet. 



CHAPTER IV. 

DENTITION. 

The part which dentition bears in the causation of disease is 
not fully ascertained. We know that the opinion formerly enter- 
tained in the profession, and now prevalent in the community, that 
a large proportion of the affections of infancy arise directly or 
indirectly from it, is erroneous. Still, many of the best authorities 
in infantile pathology concur in the belief that difficult and pain- 
ful evolution of the teeth frequently causes derangement in the 
functions of organs, even those remote from the mouth, and some- 
times produces in them a real pathological state. They, therefore, 
frequently speak of dentition as a cause of disease. On the other 
hand, there are physicians equally good observers, and the number 
is increasing, who almost wholly ignore the pathological results of 
dentition. They say that, as it is strictly a physiological process, 
it should, like other such processes, be excluded from the domain 
of pathology. Experience, they assert, corroborates this opinion, 



DENTITION. 547 

and therefore dentition should seldom, if ever, be interfered with 
by the lancet or other means. 

A moment's reflection will show how important it is to under- 
stand the exact relation of dentition to infantile diseases. Every 
physician is called now and then to cases of serious disease, in- 
flammatory and others, which have been allowed to run on with- 
out treatment, in the belief that the symptoms were the result of 
dentition. I have known acute meningitis, pneumonitis, and entero- 
colitis, even with medical attendance, to be overlooked during the 
very time when appropriate treatment was most urgently demanded. 
Many lives are lost in this manner, especially from neglected en- 
tero-colitis, the friends and even physicians believing the diarrhoea 
to be symptomatic of dentition, a relief to it, and therefore not to 
be treated. Such mistakes are traceable to the erroneous doctrine, 
long inculcated in the schools, that dentition is directly or indi- 
rectly the cause of a large proportion of infantile diseases and de- 
rangements. 

May there not be an error in the opposite direction ? May not 
some diseases be rendered milder, and their favorable termination 
more certain or probable, by measures calculated to relieve the 
turgescence of the gums ? If so, those who totally disregard the 
state of the gums are not less in error than those who use the gum 
lancet when it is not required. 

I shall endeavor to point out what is really ascertained in regard 
to the relation of dentition to disease. 

First dentition commences at the age of about six months and 
terminates at the age of two and a half years. The corresponding 
teeth of the two sides pierce the gum at about the same time. The 
two inferior central incisors first appear at about the age of six or 
seven months, followed, in the order in which they are mentioned, 
by the upper central incisors, upper lateral incisors, lower lateral 
incisors, the four anterior molars, the four canines, and, lastly, the 
four posterior molars. 

The incisors usually appear in rapid succession, so that all are 
in sight by the age of one year. From the age of one year to six- 
teen months the anterior molars penetrate the gum, from the age 
of sixteen to twenty-four months the canines, and from twenty- 
four to thirty months the posterior molars. 

This order is not always preserved. Sometimes the upper cen- 
tral incisors appear .before the lower, and sometimes the lower 
lateral before the upper lateral. In rare cases there have been 
teeth at birth. I have seen but one or two infants with such pre- 



518 DENTITION. 

mature dentition. Retarded dentition is much more common. 
Those who have rickets, or are feeble either constitutionally or by 
disease, often have no teeth till considerably after the usual period. 
In such the first incisors may not appear till the age of twelve 
months, or even later. 

Pathological Results of Dentition. — The evolution of the 
teeth is commonly attended by more or less turgescence around 
the dental bulbs. This is greater with some of the teeth than 
with others. Thus, the superior incisors cause more swelling than 
do their congeners of the inferior jaw. The turgescence, although 
it may be attended by more or less congestion, is so common that 
it is hardly proper to call it a disease. Turgescence, with redness 
and more or less tenderness of the swollen gum, may be considered 
the simplest pathological state. 

In other cases there is an unusual amount of swelling around 
the dental follicles, the afflux of blood to them is greatly aug- 
mented ; they are the seat of such a degree of tenderness and pain 
that the infant is fretful. It carries the finger often to the mouth, 
indicating the seat of its suffering. The surface over the folli- 
cles presents greater redness than in ordinary dentition, and the 
salivary secretion is considerably increased. There is now actual 
gengivitis. 

Sometimes the inflammation affects a greater extent of the 
buccal surface than that lying directly over the follicles, so that 
most writers speak of stomatitis as one of the results of dentition. 
In a few cases I have known such a degree of inflammation over 
the advancing tooth, that a small abscess formed, producing much 
pain and restlessness, till it was opened by the lancet. 

The pathological results of dentition which I have mentioned 
are unimportant in comparison with others not yet alluded to. 
They do not endanger the life of the child. They are easily 
detected. They result directly from the rapid growth and aug- 
mented sensibility of the dental follicles. 

There are other accidents of dentition occurring in distant parts 
of the system in consequence of that mysterious relation and 
interdependence of organs which exist through the system of 
nerves. 

These accidents are more serious, and their relation to dentition 
is obviously less readily ascertained, than are those located in the 
mouth. The most common of them occur in the stomach and 
intestines. 

Some children, previously to the eruption of the teeth, are 



PATHOLOGICAL RESULTS OF DENTITION. 549 

affected with diarrhoea, occasionally accompanied by irritability 
of stomach. Certain writers have supposed that gastro-intestinal 
inflammation is present in these cases ; others that there is simply 
a hyper-secretion, an increased activity of the intestinal follicular 
apparatus, that it is, in other words, one of the forms of non- 
inflammatory diarrhoea. Barrier believes that the diarrhoea of 
dentition depends usually on what he calls a " sub inflammatory 
turgescence limited to the gastro-intestinal follicular apparatus." 
He believes that, in occasional cases, it is due to defective or altered 
innervation. It would then be analogous or similar to that form 
of diarrhoea which occurs in the adult from the emotions. Bouchut 
calls the diarrhoea of dentition nervous diarrhoea. It is certain, 
however, that in most cases of diarrhoea which are attributed to 
dentition there are other causes, such as unsuitable food, or 
residence in an insalubrious locality. It is certain, as regards city 
infants, that the chief causes of diarrhoea during the period of 
dentition are strictly anti-hygienic, dentition being quite subordi- 
nate as a cause, and probably often not operating at all as such. 
But when, as sometimes happens, at each period of dental evolu- 
tion, the infant is affected with diarrhoea, the influence of teething 
is apparent. Such cases enable us to see that teething may really 
sustain a causative relation to certain diseases not located in the 
buccal cavity. 

Amono; the most common pathological results of difficult den- 
tition, are certain affections referable to the cerebro-spinal system. 
Eclampsia is one of the admitted results. Barrier attributes con- 
vulsions in the teething infant to excitement of the nervous system 
arising from the pain which is felt in the gums, and to a determi- 
nation of blood to the dental apparatus, in which afflux the whole 
vascular system of the head participates. 

In most cases of convulsions occurring during the period of 
dental evolution, a careful examination discloses other causes in 
addition to the state of the gums. Difficult dentition must then 
be considered, not so frequently a direct as a co-operating or pre- 
disposing cause, producing a sensitive state of the nervous system, 
or possibly an afflux of blood to the head, of which Barrier speaks, 
and which, by an additional stimulus, perhaps trivial in itself, 
ends in convulsions. In exceptional instances eclampsia occurs 
mainly from dentition, or, if there are other causes, they are quite 
subordinate. This may happen when several teeth penetrate the 
gum at or about the same time. Infants who are burnt or scalded 
are very liable to clonic convulsions. This is, in fact, the chief 



550 DENTITION". 

danger as regards life from such accidents. So, the swollen and 
tender gum, if several teeth are about emerging, may affect the 
cerebro-spinal system like the burn or scald, and produce the 
same nervous phenomena. Thus, in a case already alluded to in 
the chapter on convulsions, five incisors pierced the gum within 
about two weeks, and in this period there were two attacks of 
eclampsia with an interval of a few days. The attacks were not 
severe, and the most careful examination could discover no other 
cause than the simultaneous development of so many dental 
follicles. Previously, and since, the infant has been well. 

Dentition sometimes, though rarely, occasions also tonic convul- 
sions. The following case occurred in the practice of Dr. A. S. 
Church, of this city, the history of which he has kindly commu- 
nicated, as follows : — 

"E, seven months old, was first visited April 3d, 1863. The patient 
had been fretful for several days, but about daylight on the morning of 
my first visit it commenced crying, and had not ceased for a moment at 
the time of my visit, 9 A.M. The bowels were somewhat constipated 
and tympanitic ; abdominal muscles very tense. The pain was sup- 
posed to be in the abdomen, and a brisk cathartic, to be followed by 
an anodyne, was ordered. Some relief followed, but, on the ensuing 
and for several consecutive mornings, the pain returned, each day 
lasting longer, until the child only ceased crying while under the in- 
fluence of a full anodyne. The gum over the upper incisors was con- 
siderably swollen, hot, and dry, but the parents would not consent to 
have it scarified. For the first week there was no fever, no vomiting, 
and not the least indication that the nervous system was suffering. 
About the 10th the thumbs were noticed to be flexed during the attack 
of pain, and about the 15th the flexors of the toes were contracted and 
the hands were turned backwards and outwards, but only while the child 
was awake. About the 20th there was constant contraction of the flexors 
of both extremities, with opisthotonos, and constant rolling of the head, 
loss of appetite, progressive emaciation, coated tongue, and highly in- 
flamed gums. Consent was, finally, obtained to relieve the inflamed 
gum, and free incisions were made, and the following night the child 
slept comfortably for three hours without opiates. In three days the 
gums were freely cut again, and the teeth soon made their appearance. 
All symptoms of disease had now ceased, the child became playful, and 
on the 30th the patient was discharged." 

The opinion has been prevalent in the profession, that painful and 
difficult dentition is one of the chief causes of infantile paralysis, 
but it is now commonly admitted that it is only a subordinate or 
remote cause if indeed it is proper to consider it as a cause at all 
(see Art. Paralysis). 

Some writers express the opinion that acute meningitis occa- 
sionally results from teething. The facts, however, that are relied 



DIAGNOSIS — TREATMENT. 551 

upon to prove this are uncertain. The occurrence of meningitis 
during dentition is probably in most instances a coincidence. 

Teething less frequently disturbs the respiratory system than 
either the digestive or cerebro-spinal. A cough occurs in some 
infants at each period of dental evolution. It is attended by little 
expectoration, but appears to be associated with, in at least cer- 
tain cases, an inflammatory turgescence of the bronchial mucous 
membrane. 

Acceleration of pulse is often observed at the time of greatest 
swelling and tenderness of the gum. It subsides with the pro- 
trusion of the tooth. The febrile movement of dentition is ir- 
regular, sometimes presenting a remittent form, like remittent 
fever or the fever premonitory of meningitis. Eczema and certain 
other cutaneous diseases are common during dentition, but their 
dependence on it as a cause has not been demonstrated. 

Diagnosis. — The accidents of dentition which are located in the 
mouth are easily diagnosticated, except the odontalgia which 
writers describe, and which is not necessarily attended by any 
perceptible anatomical alteration of the gums. Those accidents 
which pertain to remote and concealed organs are usually detected 
with ease, though it is often difficult to determine with certainty 
their relation to dentition. 

When similar symptoms arise at each epoch of teething, and 
subside with the subsidence of the gengival turgescence, teething 
must be regarded as the cause. Or, if the disease is such as is 
known to be produced occasionally by difficult teething, and if, 
after a careful examination, we can discover no other cause, while 
the gums are swollen, especially over two or more advancing teeth, 
it is proper to refer the disease to dentition. 

It is evident that we must often be in doubt whether the disease 
which we are treating is due at all to the state of the gums, or, if 
so, whether directly or indirectly, or to what extent ; but, as a rule, 
if any other cause is apparent, we may properly regard the influ- 
ence of dentition as quite subordinate. 

Treatment. — It is obvious that remedial measures in cases of 
difficult dentition must be twofold, namely, those directed to the 
state of the gums, and those designed to relieve the derangements 
or diseases to which dentition has given rise. If there is diarrhoea, 
this should be controlled by proper remedies, so as to reduce the 
number of evacuations to two or three daily. It is well to state 
to the friends of the child, who believe that diarrhoea is salutary 
during the period of teething, that this number is quite sufficient, 



552 DENTITION". 

and that more frequent evacuations will endanger the safety of the 
child. 

The nervous affections, as convulsions, require such soothing 
and derivative measures as are recommended in our remarks on 
diseases of the nervous system. The bromide of potassium I have 
found especially useful and safe in cases of fretfulness and nervous 
excitement due to dentition. The rational employment of thera- 
peutic measures requires strict attention to he given to the causes 
of disease. Therefore, the physician called to treat an ailment, 
believed to be due to dentition, should not fail to examine the 
state of the gums, and adopt such measures as will mitigate the 
intensity of the cause — in other words, diminish the tenderness if 
not the swelling of the gum. Demulcent and soothing lotions are 
recommended by some. The infant should be allowed to hold in 
the mouth an India-rubber or ivory ring, which by pressure on the 
gum gives considerable relief. 

Mothers will often attempt to " rub through a tooth," as they 
term it, by means of a ring or thimble. This should be discour- 
aged. So great friction cannot fail to have an injurious effect, by 
increasing the swelling and inflammation, unless the tooth has 
already reached the mucous membrane. 

"We come now to a subject which has engaged the attention of 
many of the ablest and most experienced physicians, and in refer- 
ence to which there is still a difference of opinion among the 
highest authorities in medicine. I refer to scarification of the 
gums. 

The gum lancet is now much less frequently employed than 
formerly. It is used more by the ignorant practitioner, who is 
deficient in the ability to diagnosticate obscure diseases, than hj 
one of intelligence, who can discern more clearly the true patho- 
logical state. Its use is more frequent in some countries, as Eng- 
land, under the teaching of great names, than in others, as France, 
where the highest authorities, as Rilliet and Barthez, discounte- 
nance it. 

It is well to bear in mind, as aiding in the elucidation of this 
subject, the remark made by Trousseau, that the tooth is not re- 
leased by lancing the gum over the advancing crown. The gum 
is not rendered tense by pressure of the tooth, as many seem to 
think, for, if so, the incision would not remain linear, and the edges 
of the wound would not unite, as they ordinarily do by first inten- 
tion within a day or two. This speedy healing of the incision, 
unless the tooth is on the point of protruding, is an important fact, 



TREATMENT. 553 

for it shows that the effect of the scarification can only last one or 
two days. The early repair of the dental follicle is probably con- 
servative so far as the development of the tooth is concerned. It 
may help us to understand how active, how powerful, the process 
of absorption is, if we reflect that the roots of the deciduous teeth 
are more or less absorbed by the advancing second set, without 
much pain or suffering from the pressure. If the calcareous par- 
ticles of the teeth are so readily absorbed, what is the foundation 
for the belief that the fleshy substance of the gum is absorbed with 
such difficulty ? Too much importance has evidently been attached 
to the supposed tension and resistance of the gum in the process 
of dentition. 

Follicles in the period of development are especially liable to 
inflammation. We see this in the follicular stomatitis and enteri- 
tis, so common when the buccal and intestinal follicles are in the 
state of most rapid growth. Does not this law in reference to the 
follicles hold true of those by which the teeth are formed, so that 
the period of their enlargement and greatest activity, which corre- 
sponds with the growth and protrusion of the teeth, is also the 
period when they are most liable to congestion and inflammation ? 
This fact affords a better explanation of the frequency of the so- 
called laborious or difficult dentition than that it is due to the 
resistance which dental evolution encounters from the gums. 

If there are no symptoms except such as occur directly from the 
swelling and congestion of the gum, the lancet should seldom be 
used. The pathological state of the gum which would, without 
doubt, require its use, is an abscess over the tooth. As to symp- 
toms which are general or referable to other organs, as fever and 
diarrhoea, the lancet should not be used if the symptoms can be 
controlled by other safe measures. All co-operating causes should 
first be removed, when in a large proportion of cases the patient 
will experience such relief that scarification can be deferred. 

If the state of the infant is such that life is in danger, as in 
convulsions, or there is danger that the infant will be permanently 
injured or disabled, as by paralysis, every measure which can 
possibly give relief should be employed without delay. In these 
dangerous nervous affections, therefore, the gums if swollen should 
be lanced. I know no accidents of dentition which require prompt 
scarification except suppurative inflammation of the gums, convul- 
sions, and paralysis. In other cases the operation may be safely 
postponed till other measures have been employed. 



554 DENTITION. 

Second Dentition. 

The fact is well established, though often overlooked in prac- 
tice, that second dentition occasionally deranges the functions of 
organs, and gives rise to pathological symptoms. Billiet and 
Barthez mention particularly neuralgic pains, rebellious cough, 
and diarrhoea, as effects which they have observed. Eilliet re- 
lates the case of a girl eleven years old, who had a very obstinate 
and protracted cough, the paroxysms lasting often half an hour 
to an hour. This cough immediately and permanently disappeared 
when the molars pierced the gums. 

Dr. James Jackson, in his Letters to a Young Physician, says: 
"I have seen persons between twenty and thirty years of age 
much affected by a wisdom tooth not yet protruded, and distinctly 
relieved by cutting the gum. But I think the most common 
period of suffering from the second dentition is from the tenth 
to the thirteenth year. The most characteristic affections are 
wasting of flesh and nervous diseases. The boy loses his comeli- 
ness, and his complexion is less clear, while emaciation takes place 
in every part, though mostly, perhaps, in the face. The nervous 
symptoms are various, but the most common are a change in the 
temper and a loss of spirits. With these there is some loss of 
strength. The patient is unwilling to engage in play, and soon 
becomes tired when he does do it. Among the distinct symptoms 
which are not uncommon, I may mention pain in the head and in 
the eyes. The headache is not commonly severe, but it is such as 
inclines the patient to keep still. The eyes are not only painful, 
but are often affected with the morbid sensibility to which these 
organs are subject. I have known boys truly anxious to pursue 
their studies obliged to give them up on this account ; and these, 
not having the disposition to play, will of choice pass the day with 
their mothers, and increase their troubles by the want of air and 
exercise. Nervous affections of a more severe character are some- 
times manifested." 

"Whether the symptoms which have been attributed to second 
dentition have always been due to this cause, is questionable. 
Practically, however, it matters little, whether we recognize 
dentition as the cause, or assign something else. Hygienic and 
medicinal measures to improve the general health will usually 
suffice to relieve the patient. I have known a boy, pallid and of 
nervous temperament, about seven years old, recover immediately 
from a cough which had lasted for several weeks, by taking three 



PHARYNGITIS — ANATOMICAL CHARACTERS. 555 

times daily a mixture of iron and nitric acid. Many do well 
without medicine, simply by hygienic measures. Dr. Jackson 
says, " The remedies which I have found most useful are as 
follows : First, a relief from study or from regular tasks, yet using 
books so far as they afford agreeable occupation or amusement. 
Second, exercise in the open air, preferring the mode most agree- 
able to the patient, and in more grave cases the removal from town 
to countrv." 



CHAPTER Y 



SIMPLE PHARYNGITIS. PERI-PHARYXGEAL ABSCESS, 
(ESOPHAGITIS. 

Children of all ages are liable to inrlammation of the pharynx. 
In its mildest form it often, doubtless, escapes detection in the 
young infant. In older patients it is revealed by pain in swallow- 
ing solid food, and more or less tumefaction below the ears 
apparent to the sight. It is said to be less frequent in infancy 
than in childhood. In the adult, and in children over the age of 
four or five years, inflammation of the pharyngeal surface is often 
confined to the portion of membrane which covers or immediately 
surrounds the tonsils. It occurs in connection with inflammation 
of these glands. But in infancy and early childhood this limita- 
tion is comparatively rare. Inflammation of the throat at this age 
is ordinarily a general pharyngitis, the tonsils participating in the 
morbid state. 

Pharyngitis is primary or secondary. The secondary form 
occurs in measles, scarlet fever, bronchitis, croup, pneumonitis, 
and occasionally in other affections. As these diseases are com- 
mon, physicians are oftener called to treat patients who have the 
secondary form than the primary. Rilliet and Barthez met eighty- 
three secondary to sixteen primary. 

Axatoiucal Characters. — The pathological anatomy of pha- 
ryngitis is ascertained by depressing the tongue and inspecting 
the fauces. The membrane lining the fauces is seen to be redder 
than in health, and presenting a more or less swollen appearance, 
according to the intensity of the inflammation. In idiopathic 
pharyngitis, the fauces commonly have a bright red hue, almost 
like that of arterial blood. If, on the other hand, the inflamma- 



556 SIMPLE PHAKYNG-ITIS. 

tion occurs in connection with a constitutional affection, the hue 
is apt to be darker. In grave cases of scarlet fever or measles, it 
is sometimes even livid, indicating a vitiated state of the blood, a 
condition of real danger. The tonsils are tumefied so as to pro- 
ject, though not to the extent which we often observe in the adult. 
They are also less firm than in the normal state. The follicles of 
the throat are enlarged and active, pouring out a muco-purulent 
secretion. This is sometimes seen in a layer over the tonsil or the 
posterior portion of the fauces. In a case of primary pharyngitis 
examined after death by Rilliet and Barthez, the tonsils were 
softened, infiltrated with pus, and slightly enlarged. A layer of 
bloody mucus lay on the pharynx, and the pharyngeal surface was 
dark red, thickened and granular. The submaxillary glands were 
also swollen and somewhat softened. 

If the inflammation is intense, the deep-seated portion of the 
tonsil becomes involved, and even sometimes the adjacent con- 
nective tissue. In most cases, by applying the finger in the hollow 
below the ears, the tonsil can be felt. In severe cases, also, the 
submaxillary glands are tumefied. 

Causes. — The usual cause of primary or idiojDathic pharyngitis 
is exposure to cold. It also occasionally occurs from the use of 
drinks too hot or containing some irritating substance. I have 
met it in the most intense form caused by swallowing boiling 
water, and, in one case, from acetic acid taken through mistake. 
When it occurs from the eruptive fevers, it is part of a more 
extensive mucous phlegmasia, although the inflammation is often, 
as in scarlet fever, more intense in the pharynx than elsewhere. 

Symptoms. — Tenderness of the pharynx, and pain on swallowing, 
announce pharyngitis. These symptoms are not so readily detected 
in infancy as in childhood. They are not always proportionate to 
the intensity of the inflammation. The tongue is slightly furred ; 
there is thirst, and the appetite is more or less impaired. The 
breath is foul, but not fetid; the respiration is normal, or but 
slightly accelerated ; cough is sometimes present, sometimes absent. 
When present, it is due to extension of inflammation to the upper 
part of the larynx, or to the collection of mucus around the aper- 
ture of the glottis. 

When the tonsils are considerably enlarged, and the adjacent 
parts much swollen, the voice is sometimes much altered, present- 
ing a nasal character. The pulse in pharyngitis is accelerated, 
and the temperature of the surface elevated according to the 
severity of the inflammation. 



PROGNOSIS — DIAGNOSIS — TREATMENT. 557 

Prognosis. — In mild cases of pharyngitis convalescence com- 
mences within a week. If the inflammation is dependent on a 
constitutional affection, it may continue a much longer time, 
especially if the glands of the neck and the connective tissue are 
much involved. The prognosis of secondary pharyngitis is less 
favorable than that of the primary form. In fatal cases there is 
usually a vitiated state of the blood, either from the coexisting 
constitutional disease, or from previous cachexia. The younger 
the child, also, the less favorable the prognosis. 

Pharyngitis may, however, become dangerous from complica- 
tions to which it gives rise. The proximity of the inflammation to 
the brain, or its effect upon the cerebro-spinal axis through the 
medium of the nerves, sometimes gives rise to clonic convulsions. 
In a recent case of primary pharyngitis in my practice, repeated 
and violent convulsions occurred in an infant, about one year old, 
from this cause. They commenced at the inception of the inflam- 
mation, and constituted the only real danger. Pharyngitis may 
interfere materially with nutrition in consequence of the dyspha- 
gia, but in most cases of primary pharyngitis this symptom does 
not continue sufficiently long to endanger the life of the patient. 
In grave constitutional affections, as scarlet fever, the difficulty of 
swallowing, and the consequent innutrition, augment the danger. 
As regards, therefore, the prognosis in simple pharyngitis, whether 
primary or secondary, it may be stated as a rule, that it is not, per 
se, a fatal disease, but is only so from complications, or from 
aggravating the primary affection with which it is associated. 

Diagnosis. — This is never difficult provided attention is directed 
to the throat ; but the physician often fails to discover it at his first 
visit, from neglecting to examine this part. In many cases the 
local symptoms are not well-marked, and in the absence of these 
the febrile reaction may at first be referred to some other cause 
than the true one. Inspection not only reveals the presence of 
inflammation, but enables us to determine whether it is simple 
pharyngitis, or diphtheritic, or ulcerative. In some instances, 
simple pharyngitis resembles diphtheritic, from the presence of 
confervoid growths upon the inflamed surface, usually the lepothrix 
buccalis. The differential diagnosis is based on the easy removal 
and soft pultaceous character of the confervas, and the appearance 
under the microscope. 

Treatment. — Mild cases of simple pharyngitis require little 
treatment. With moderate counter-irritation over the throat, and 
the use of laxative medicines, the inflammation soon subsides. 



558 SIMPLE PHAEYNGITIS. 

The liniment urn camphorse may be occasionally rubbed over the 
throat, and retained upon it by flannel. The effect is increased 
by the application, once or twice daily, of mustard or tincture of 
iodine, or by adding to the liniment a little volatile liniment or 
turpentine. Mucilaginous and refrigerant drinks, with a light 
diet, suffice to complete the cure. 

In the severe form of idiopathic pharyngitis more active mea- 
sures are required. The bowels should be freely opened, warm 
mustard pediluvia occasionally employed, and the head be kept 
cool. If the patient is robust, as in the first stages of the disease, 
and there is threatening of cerebral complication, it is proper to 
apply one or more leeches to the temples or neck ; but cases re- 
quiring such depletion are exceptional. 

Diaphoretics and sometimes cardiac sedatives are indicated, such 
as liquor ammonise acetatis, spiritus setheris nitrosi, ipecacuanha, 
tartrate of antimony and potassa, aconite, and veratrum viride. 
Medicines of this kind may be variously combined according to 
the age and condition of the patient, and the severity of the dis- 
ease. Saline laxatives are also in some cases useful. 

As the symptoms abate, the intervals between the doses may be 
increased. In those cases of severe idiopathic pharyngitis attended 
by pain in deglutition, moderate but constant counter-irritation 
should be employed over the seat of inflammation. An excellent 
application, and one much used in families, is a slice of fat salt 
pork, cut as thin as possible, stitched on a single thickness of muslin, 
and applied from ear to ear. It is better, usually, to sprinkle more 
salt upon it, and sometimes powdered camphor. 

In cases of much tenderness and dysphagia great relief is often 
obtained by emollient poultices applied over the throat. Mustard 
or iodine may also be occasionally employed in addition if there is 
not already sufficient counter-irritation. 

Topical treatment of the pharynx is recommended by most 
authors. Rilliet and Barthez use for this purpose nitrate of silver 
or powdered alum. The former has been most employed by phy- 
sicians. It may be applied in the proportion of ten grains to the 
ounce, two or three times daily. I have commonly prescribed the 
liquor ferri subsulphatis mixed with three or four times its quantity 
of glycerine, for application to the inflamed part, and with a good 
result. 

Gargles, which we so often prescribe in the pharyngitis of 
adults, cannot be satisfactorily employed in infancy and early 
childhood. 



PERI-PHARYNGEAL ABSCESS. 559 

The treatment of secondary pharyngitis will he described in 
connection with the treatment of the diseases which it complicates. 
Suffice it here to say that this form of inflammation must not be 
treated by those depressing remedies which are useful in certain 
cases of idiopathic pharyngitis. 

Pseudo-membranous pharyngitis, or diphtheria, being a constitu- 
tional disease, has been described elsewhere. 

Feri-Pharyngeal Abscess. 

Every practitioner should bear in mind the fact that an abscess 
occasionally forms between the pharynx and vertebral column 
(retro-pharyngeal), or upon the sides of the pharynx in the sub- 
mucous connective tissue. This constitutes a disease which is apt 
to be fatal, but which can ordinarily be promptly relieved by the 
surgeon. 

Yet, if we look over the records of peri-pharyngeal abscess, we 
shall see that in a large proportion of published cases, the disease 
was supposed to be something else, and so treated until its nature 
was revealed by post-mortem examination. The most complete 
monograph on this disease with which I am acquainted was pub- 
lished by Dr. Allin, of this city, in the W. Y. Journ. of Med. for 
"Nov. 1851, under the title of retro-pharyngeal abscess. To this 
paper I am largely indebted for facts. 

Age — Cause. — This disease may occur at any age ; but it is 
most common in infancy and childhood. It is more frequent in 
the first year of life than at any other period. Of the cases collated 
by Dr. Allin, in which the age is stated, twenty were under ten 
years, while the number for all other ages was twenty-one. This 
disease arises in some patients from caries of the vertebral column, 
and, in others, from inflammation commencing with the mucous 
membrane of the pharynx, and extending to the submucous con- 
nective tissue. Whichever the cause, there is usually a scrofulous 
or reduced state of system. 

Writers describe two kinds of peri-pharyngeal abscess, the pri- 
mary and secondary. This distinction is based on the fact, 
whether or not the inflammation which leads to the abscess is de- 
pendent on an antecedent pathological state. 

In the primary form the cause is usually atmospheric, or it is 
some irritating substance which has been swallowed, and which, 
lodging in the pharnyx, produces pharyngitis. 

The cause is mentioned in twenty cases of the primary form, 



560 PERI-PHARYNGEAL ABSCESS. 

collated by Dr. Allin, as follows: exposure to cold, ten cases; 
lodgement of bone in pharynx, eight cases ; blow with a fencing 
foil, one case. In the last case, the button of a fencing foil passed 
through the right nostril into the pharynx. 

The secondary form occasionally occurs after measles and scarlet 
fever. The inflammation of the pharynx, common in those dis- 
eases, extends to the subjacent connective tissue, and, aided by the 
dyscrasia of the patient, becomes suppurative. Such cases have 
been observed by BJlliet and Barthez. The most common cause 
of the secondary form is, however, caries of the vertebral column. 

When thus occurring it is similar, both as regards cause and 
nature, to lumbar abscess. It would follow the same chronic 
course, and would properly be described in connection with it, 
were it not for its proximity to the air passages, which renders 
the disease so rapid and fatal. In a few recorded cases the abscess 
has been a sequel of erysipelas. It is believed by some that when 
it thus occurs there is retrocession of the erysipelatous eruption. 
In nineteen cases of secondary abscess in Dr. Allin's collection, 
the cause is assigned as follows : erysipelas of face, two ; inflamma- 
tion following a fall upon the inferior maxilla, one ; after cerebri- 
tis, one ; syphilis, four ; caries of the cervical vertebra, six ; scrofula, 
five. 

The proximate cause of peri-pharyngeal abscess is believed by 
Mr. Fleming {Dublin Journ. of Med. Sci. vol. xvii.) to be in some 
instances inflammation of small lymphatic glands lying in the con- 
nective tissue external to the pharynx. After remarking that two 
cases which he reports lend confirmation to this view, he con- 
tinues : " That those glands are only occasionally found in this 
situation, I admit, and hence, probably, the rare occurrence of this 
particular form of disease, but that they exist more frequently 
than is generally imagined, I am equally certain." Prof. Geo. T. 
Elliot relates a case (Obstet. Clinic, N. F., Appleton & Co., 1868) in 
which peri-pharyngeal abscess immediately followed and was appa- 
rently due to parotiditis. The patient was a boy seven months 
old. 

In rare instances the abscess, or the local disease which leads to 
it, appears to exist from birth. Thus, Dr. E. 0. Hocken relates, in 
the Prov. Med. and Surg. Journ., 1842, the history of an infant 
who died at the age of nine weeks. It had always, when taking 
the breast, thrown back its head as if nearly suffocated. The 
walls of the abscess were thick and firm, described by the writer 



ANATOMICAL CHARACTERS — SYMPTOMS. 561 

as cartilaginous. Occasionally there is no apparent cause of the 
abscess. We must then attribute it to some unknown dyscrasia. 

Anatomical Characters. — The seat of the abscess is not the 
same in all cases. The swelling can ordinarily be seen on exami- 
ning the fauces, but occasionally it is so low as to be really peri- 
esophageal, and therefore invisible. The size of the abscess varies ; 
sometimes it is large, pressing inward the wall of the pharynx 
even against the velum palati and into the posterior nares, if the 
abscess have a high location, or, if lower, against the larynx, so 
as to embarrass respiration. Sometimes the abscess is so large or 
has such lateral extension that there is external swelling along the 
side of the neck. In a few cases on record the pus, instead of 
being discharged into the pharynx, made its way down the neck 
between the muscles and the connective tissue to the pleural cavity, 
which it entered, producing fatal pleuritis. 

The walls of the abscess have been found in a different state in 
different cases. Sometimes the sac, at the projecting point, is so 
thin that it seems as if there might have been a spontaneous cure, 
could life have been preserved a few hours longer. In other cases 
the sac is so thick and firm that its rupture, for many days, would 
be impossible. 

Symptoms. — The precursory symptoms differ in different cases, 
according to the nature of the cause, whether it be pharyngitis, 
glandular inflammation, or vertebral caries. If the abscess proceed 
from caries, it is preceded by deep-seated and protracted pain, 
greatly increased by movements of the head. 

The patient with this disease is restless, his mouth hot and dry ; 
tongue furred; deglutition more or less difficult. Sometimes after 
suppuration has occurred there are alternations of heat and chills. 
The symptoms indicate approximately the seat of the inflamma- 
tion, but on examination we do not find that degree of redness 
and swelling of the mucous surface which we had been led to 
expect. The tissues which are chiefly involved in the inflamma- 
tion, being submucous, are hidden from view. We observe redness 
of the pharynx, but it is disproportionate to the intensity of the 
symptoms. Sometimes there is a sensation of chilliness through 
the entire period of the abscess, though greater at one time than 
at another, and occasionally convulsions occur, especially in young 
infants. In ordinary cases the embarrassment of respiration is 
one of the first and most conspicuous of the symptoms, and it is 
the cause of the chief danger. It becomes more and more marked 
as the abscess increases. It is noticed both during inspiration and 
36 



562 PERI-PHARYNGEAL ABSCESS. 

expiration. The dysphagia also increases, sometimes to such a 
degree that drinks are taken with difficulty, and solid food refused. 
The respiratory symptoms bear considerable resemblance to those 
in protracted laryngitis, for which this disease has been mistaken. 
While the respiration becomes impeded or whistling, the voice is 
also feeble or indistinct, from the pressure of the tumor. 

But the symptoms described above are not all present in every 
case. They vary according to the size and location of the abscess, 
whether it be high or low, posterior or lateral. I have met the dis- 
ease in a child old enough to express its subjective symptoms, in 
whom there was little or no dysphagia, and others report similar 
cases. "When the tumor has attained such a size as to produce well- 
marked symptoms and jeopardize the life of the patient, it, or a 
part of it, can ordinarily be seen on depressing the tongue, but 
usually its location and condition can be better ascertained by 
exploration with the finger. The dyspnoea increases as the abscess 
enlarges, and, after a time, unless it bursts spontaneously or is 
opened by the surgeon, imperfect oxygenation of the blood results. 
In some patients paroxysms of dyspnoea occur, so as to threaten 
immediate suffocation; coughing or attempts to swallow induce 
these paroxysms, 'and the patient is forced to remain in an erect or 
semi-erect posture. The tongue is protruded, the head thrown 
back, the pulse is frequent and rapid, the limbs become livid and 
cool, and finally death occurs from apnoea. Occasionally, when 
death seems inevitable, the abscess gives way by the struggles of 
the child, and the patient is restored to health. In rare cases the 
result is different. The trachea and bronchial tubes are deluged 
by the purulent discharge, and immediate suffocation occurs. The 
following was an example: In May, 1871, a boy two years and 
five months old was brought to the Clinic at Bellevue, who had 
bad the symptoms of an abscess for three months. The head was 
carried one side, its rotation caused pain, and a laryngeal rale 
.accompanied respiration. The upper part of the tumor could be 
.detected by the finger, but, on account of its low location, it was 
impossible to open it with the bistoury. The temperature was 
103°, pulse 156. The case was kept under observation, but in a 
few days the dyspnoea suddenly became so urgent that death was 
imminent, when the attending physician of the class, Dr. Swezey, 
broke the abscess with his finger, and pus was ejected on the floor; 
death, however, occurred almost immediately. 

A correct appreciation of the symptoms and the nature of peri- 
pharyngeal abscess will be best obtained by relating a case. I 



SYMPTOMS. 563 

select the following from the Transactions of the London Pathological 
Society, October 20th, 1846:— 

A female infant died at the age of seven months, having had 
difficult breathing three weeks, and extreme dyspnoea during the 
last days of life. The dyspnoea was constant, and was aggravated 
by mental excitement, by movements of the body, and by exposure 
to cold. During the paroxysms, a peculiar, croupy sound accom- 
panied inspiration. There was no dysphagia through the entire 
sickness, and death occurred from apncea. 

The sac of the abscess was of the size of a pigeon's egg, and 
was situated between the upper cervical vertebrae and the back 
of the pharynx. The abscess was flattened in front, so as not to 
cause any material prominence of the wall of the pharynx. From 
the sac a second small cyst extended forward, forming a nipple- 
like swelling in the pharynx, which completely closed the orifice 
of the glottis. Its aperture of communication with the body of 
the abscess admitted the point of the little finger, and the whole 
swelling was freely movable and perfectly translucent at its ex- 
tremities and sides. The abscess might have been easily punctured, 
with probably the preservation of life. 

The duration of this disease is very different, according to the 
severity of the inflammation, the rapidity with which the abscess 
enlarges, and the direction which it points. A lateral or down- 
ward extension is not so immediately dangerous to life as the 
anterior. 

The time when the abscess begins to form cannot be precisely 
ascertained, and most writers, in determining the duration of the 
disease, compute from the first appearance of symptoms which 
are referable to the pharynx. Dr. J. Bryne relates, in the Amer. 
Journ. of Med. Sci., 1838, a fatal case in which the disease had 
apparently continued only about one week. The patient was an 
infant one year old, and died* of apncea. The abscess was large, 
extending from the base of the skull to the thorax, and pressing 
both on the larynx and trachea, i M. Besserer (Arckiv. Gen. de 
Med., 1840) gives the history of an infant four months old, who 
died in the same way after thirteen days. An infant nine months 
old, whose case was published by Dr. "W". C "Worthington, in the 
JProv. Med. and Surg. Journ., 1842, lived nine days. The abscess 
occurred from exposure to cold ; the patient was treated for croup, 
and died from suffocation. The anterior wall of the abscess was 
very thin. Since the first edition of this book was published, I 
have met three patients with this disease in whom the pus was 



664: PERI-PHARYNGEAL ABSCESS. 

evacuated when the dyspnoea had become urgent. In two the 
symptoms indicated a continuance of the disease from two to four 
weeks, and in the third case four months. 

When the abscess grows slowly, and presses lightly on the air- 
passages, the case may continue for months. Such a one was 
observed by Prof. Willard Parker (Allin). This infant was one 
year old ; it suffered from pharyngeal symptoms nine months, was 
treated for tonsillitis, and death occurred as usual from apnoea. 
The abscess was two inches long, and there was no disease of the 
vertebrae. The same surgeon saved the life of another patient four 
years old, in whom the disease was chronic, by puncturing the 
abscess ; and Prof. Post, of this city, also treated successfully a 
case which had continued three months. (Allin.) 

Diagnosis. — The diagnosis of this - disease is ordinarily not 
difficult, provided the physician examine carefully and bear in 
mind the occasional occurrence of such an abscess. In a large 
proportion, however, of the recorded fatal cases, the true nature 
of the disease was not recognized during life. Especially is the 
diagnosis difficult when the cerebro-spinal system is early impli- 
cated, and symptoms arise which divert attention from the throat 
to the brain. 

The diseases with which peri-pharyngeal abscess is most fre- 
quently confounded are laryngitis and simple but severe pharyn- 
gitis. From laryngitis, for which it has been most frequently 
mistaken, it may be distinguished by the dysphagia and by the 
character of the initial symptoms. In laryngitis there is usually 
the peculiar cough from the first or very early, while in abscess 
there is a period of several days or even weeks before respiration 
is materially affected. 

In abscess pressure of the larynx backward is badly tolerated, 
greatly increasing the dyspnoea, while in pharyngitis and croup 
this effect is not so marked. In abscess the horizontal position 
aggravates the dyspnoea, but not in pharyngitis and croup. The 
character of the voice will also aid in diagnosticating abscess 
from laryngitis, since in the former it is apt to be nasal, and in 
the latter hoarse or whispering. The decisive test is afforded by 
inspection and digital exploration. The tumor is seen, or, if 
situated too low to be seen, is felt, upon the walls of the pharynx. 

If the symptoms of abscess are masked by those arising from 
the cerebro-spinal system, as by convulsions, the priority of the 
pharyngeal symptoms will serve to aid in determining the true 
disease. 



PROGNOSIS — TREATMENT. 565 

In a case of suspected abscess the physician should not only 
carefully inspect the fauces, but should employ digital examination. 
The finger will sometimes detect fluctuation when no evidence of 
an abscess is presented to the eye. Two cases observed by Prof. 
Elliot (Obstet. Clinic, p. 420) were examples in point. 

Prognosis. — With proper treatment the result is usually favora- 
ble, but, if the disease is not recognized, the majority die. In Dr. 
Allin's cases, of those under the age of twelve years nine died, 
while ten recovered by the opening of the abscess by the lancet, 
trocar, or finger, and one by its spontaneous rupture. 

If the abscess is due to disease of the spinal column, death may 
occur immediately after the sac is opened, the caries of the inter- 
vertebral cartilages producing, according to Dr. Allin, dislocation 
of the vertebrae. Death may also occur, though rarely, from pleu- 
ritis, in consequence of the bursting of the abscess into the pleural 
cavity. Even in caries, if the sac is properly opened, and if need 
be reopened, recovery is possible, as in a case treated by Prof. 
Post. 

Treatment. — The proper treatment of peri-pharyngeal abscess 
is simple, consisting in breaking, or puncturing the sac by the fin- 
ger, the lancet, bistoury, or pharyngotome. Each method has 
been successfully employed. In the majority of cases the proper 
way to open the abscess is by the ordinary curved scalpel or bis- 
toury, which should be covered by a strip of adhesive plaster to 
within a half inch of the point. If the abscess is post-pharyngeal, 
it should be opened in the median line. A single incision suffices 
to evacuate the pus. If the abscess points or is elastic, there is 
little danger of wounding any important vessel or producing dan- 
gerous hemorrhage if the operation is properly performed. It may 
be necessary to open the abscess more than once, as in a case re- 
ported by Dr. Post, and another which I saw with Dr. Livingston 
of this city. In certain cases, when the knife can not be readily 
employed, the abscess may be opened by pressure with the finger 
nail or the edge of a teaspoon. 

Patients with this disease ordinarily require constitutional treat- 
ment, especially the use. of tonics, ferruginous and vegetable. The 
citrate of iron and quinine, the citrate of iron and ammonia, and 
in strumous cases the syrup of the iodide of iron with cod-liver 
oil, are eligible preparations. Nutritious diet and often alcoholic 
stimulants are required. 



566 (ESOPHAGITIS 



Oesophagitis. 



Disease of the (esophagus in infancy and childhood is compara- 
tively rare, inflammation being the most frequent affection of this 
portion of the digestive tube in these periods, and, indeed, the only 
one which claims attention. It is most common in infants under 
the age of three or four months, who are deprived of the breast 
milk, and are given a diet which is with difficulty digested, and 
perhaps taken too hot or too cold. It is, therefore, most frequent 
in foundling hospitals. I have frequently observed it in the In- 
fant's Hospital, and the Nursery and Child's Hospital, of this city, 
chiefly at the autopsies of bottle-fed infants, under the age of six 
months, whose symptoms had indicated disease or derangement of 
the digestive function, Many of them had diarrhoea, and died in 
a state of emaciation. Oesophagitis in these cases was associated 
with simple or gangrenous stomatitis, thrush, or with gastritis or 
entero-colitis. Sometimes all these inflammations coexisted. In a 
few cases the confervoid growth of thrush had extended from the 
mouth to the oesophagus. It occurred in small hemispherical 
masses, scarcely as large as a pin's head. Swallowing corrosive or 
strongly irritating substances, as the acids or alkalies, is an occa- 
sional cause of oesophagitis, the irritant at the same time producing 
stomatitis and gastritis. 

Anatomical Characters. — The inflamed surface sometimes 
presents a uniformly injected appearance. Usually, however, 
there is greater intensity of inflammation in streaks or patches 
than over the surface generally. I have frequently observed at 
autopsies a greater degree of inflammation in the lower than upper 
half of the oesophagus, even when the infant had stomatitis at the 
time of death. 

Oesophagitis occurring from faulty regimen or anti-hygienic con- 
ditions is not accompanied by as much thickening of the walls of 
the tube as often occurs in some other portions of the digestive 
canal, as, for example, in the colon. In diphtheritic inflammation 
of the oesophagus there are more submucous infiltration and thick- 
ening of the mucous membrane than in simple oesophagitis. 

Occasionally ulcerations of the oesophageal mucous membrane 
are observed in the lower part of the tube, and Billard describes 
the ulcerative form of oesophagitis. At the first autopsies at which 
I observed these ulcers, I supposed that they were pathological, 
and indicated a severe grade of inflammation ; but a more extended 
observation has convinced me that they are usually post-mortem, 



INDIGESTION. 567 

and are not at all dependent on inflammation of the oesophagus. 
The solvent power of the gastric juice not only causes ulceration 
in the stomach, but entering the oesophagus may and not infre- 
quently does produce a solvent action on the mucous tissue there. 
At the meeting of the London Pathological Society, March 4th, 
1852, Dr. Grraily Hewitt presented a specimen in which the gastric 
juice had not only eaten entirely through the coats of the oesopha- 
gus an inch above the stomach, but had even attacked the left lung. 
Over the age of six months inflammation of the oesophagus is rare. 

The symptoms of oesophagitis, in those young and emaciated 
infants in whom it ordinarily occurs, are not well pronounced. If 
they have pain in deglutition, or tenderness on pressure over the 
oesophagus, it is not apparent. Nor have they seemed to me to 
vomit oftener than other infants of this class suffering from indi- 
gestion and gastro-enteritis, without oesophagitis. It is, therefore, 
difficult to diagnosticate oesophagitis. It is, according -to my 
observation, oftener present than absent in spoon-fed infants of 
three months or under who have persistent stomatitis and entero- 
colitis. 

Treatment. — In the oesophagitis of foundlings and ill-nourished 
infants, which arises, as has been stated, from faulty regimen, no 
treatment is required apart from that designed to relieve the 
stomatitis or entero-colitis with which it exists. Attention must 
be directed mainly to the diet and hygienic management. The 
remedial measures are more fully detailed in our remarks on entero- 
colitis. Oesophagitis produced by swallowing corrosive or highly 
irritating substances requires the same treatment as in the adult, 
namely, poultices, demulcent drinks, perhaps leeches, etc. 



CHAPTER VI. 

INDIGESTION, CONGESTION OF STOMACH, GASTEITIS, FOLLICU- 
LAR GASTRITIS, DIPHTHERITIC GASTRITIS, POST-MORTEM DI- 
GESTION, SOFTENING. 

Indigestion is much more common during infancy than in any 
other period of life. "While the digestive organs in the adult 
easily assimilate a great variety of food, it is necessary for the 
well-being of the infant that its diet be simple and carefully pre- 



568 INDIGESTION. 

pared. Departure from this rule leads to indigestion and ulterior 
diseases. 

After the age of two years a mixed diet is readily assimilated, 
the digestive function less frequently disordered, and indigestion 
presents few peculiarities to distinguish it from that of the adult. 

Indigestion in some children is habitual; in others the digestive 
process is ordinarily well performed, but, from some temporary 
derangement of system or error of diet, an acute attack of indiges- 
tion occurs. Hence, two forms of this ailment may be described : 
first, acute, referring to temporary attacks; secondly, chronic, 
referring to the habitual state. 

Causes. — The causes of indigestion are twofold: first, the con- 
condition of the digestive function independently of the aliment ; 
secondly, the unwholesome or improper character of the ingesta. 
Anything which lowers the vital powers may be a predisposing 
cause of indigestion, by impairing the functions of some of the 
organs which assimilate the food. Impure air and personal 
uncleanliness, protracted hot weather, and previous disease, are 
among the common predisposing causes. The strong country 
child can thrive upon a diet which, given to the more feeble child 
of the city, would produce deleterious results. During the sum- 
mer months it often happens that an infant in the city cannot 
digest properly any food given to it except the mother's milk; 
and from this results much of the infantile sickness and mortality 
which make this season of the year so much dreaded by parents. 
There is a natural difference in children, as regards liability to 
disordered digestion. Some do well upon a diet which given to 
others similarly situated occasions vomiting, gastralgia, and flatu- 
lence. 

In the majority of cases of indigestion, however, the fault does 
not exist in the child. It is fed too often or irregularly, or upon 
a diet that is unwholesome or indigestible. It is well known that 
the milk of the mother or the wet-nurse is liable to changes 
which render it for the time unsuitable for the infant. Her food 
may be of such a quality, or her mind so excited, or some func- 
tion of her system so disordered, as to effect a temporary change 
in the constitution of the milk. The occurrence of the catamenia, 
or of gestation, in mothers who are suckling, not infrequently pro- 
duces this unfavorable result. 

Indigestion is most common in those infants who, deprived of 
the mother's milk, are intrusted to wet-nurses, or fed from the 
bottle. The milk of the wet-nurse, from not agreeing with the 



SYMPTOMS. 569 

age of the infant, from irregularity in her mode of life, from the 
acescent nature of her food, or from other causes which are hot 
appreciable, may disagree with the infant, and be imperfectly 
digested. 

The most common cause of indigestion in the infant is artificial 
feeding. This, in the cities, is productive of a great amount of 
gastric and intestinal derangement and disease. The younger the 
infant, the less likely is it to thrive if brought up by hand. 

"Whatever care may be bestowed in the preparation of its food, 
whether cow's or goat's milk or farinaceous substances be used, 
there is seldom that healthy nutrition which is observed in infants 
who receive the natural aliment. The " swill milk" in common 
use among the poor families of this city is totally unfit for children 
of any age, and is apt to produce flatulence, acidity, and indiges- 
tion. Acute indigestion occurs in children of any age from food 
unsuitable in quality or quantity, which produces gastralgia and 
other symptoms to be detailed hereafter. Those who suffer 
habitually from mal-assimilation are especially liable to such acute 
attacks. 

In the period of childhood, chronic indigestion is much less 
frequent than in infancy, but children are, perhaps, more subject 
than infants to the acute form. This is induced by ingesta taken 
in too large quantity, or of a kind which is with difficulty digested. 
Cherries, currants, raisins, the parenchyma of oranges and lemons, 
dried fruits and confectionery, which are so often heedlessly given 
to children, are common causes of acute attacks of indigestion. 
These substances, being but partially digested or not at all, and 
sometimes accumulating for days in the stomach or intestines, may 
lead to a very serious and dangerous condition. 

Symptoms. — The nursing infant, if the milk continually disagree 
with it, is fretful." It has a discontented aspect. It seldom smiles, 
and is not amused by playthings, or is only amused for a short 
time. Its features are pallid, and bear the appearance of faulty 
nutrition. Its body and limbs are more or less wasted, or are soft 
and flabby. Vomiting is frequently present, and sometimes a large 
mass or masses of caseum are ejected, which have evidently lain a 
considerable time in the stomach. The bowels may be constipated 
or loose, and the evacuations are unhealthy. This state of the 
infant continuing prevents the necessary rest of the mother, and 
may affect unfavorably her health, so as to reduce the quantity of 
her milk, or render it still more unwholesome. 

In addition to the habitual indigestion, these infants sometimes 



570 INDIGESTION. 

have acute attacks, similar to the acute dyspepsia of adults, and 
which have been described by writers as gastralgia or enteralgia. 
Their countenance indicates suffering ; they utter sharp cries, and 
their thighs are drawn over the abdomen, indicating the seat of 
the suffering. Flatulence is common. By vomiting or an evacu- 
ation from the bowels, the offending substance is removed, and the 
pain subsides. 

Indigestion in the spoon-fed infant is similar to that in the in- 
fant who nurses, except that it is ordinarily accompanied by 
symptoms of greater gravity and persistence, and there is in the 
spoon-fed more liability to the acute attacks. 

In those who have advanced beyond the age of infancy, chronic 
indigestion is less frequent than in infants, but as the diet of such 
children is prepared with less care, and is less restricted, they 
are very liable to attacks of temporary indigestion. These come 
on suddenly, and sometimes are so severe as to endanger life. 
The child, previously well, is suddenly seized with languor; the 
pulse becomes accelerated, the face flushed, and surface hot. 
Drowsiness compels him to seek the bed, where he lies with his 
eyes shut. He sometimes has headache, and a sensation of oppres- 
sion in the epigastrium. The nervous system is not unfrequently 
affected, as shown by tenderness of a neuralgic character of the 
body and limbs, sudden twitching of the limbs premonitory of con- 
vulsions, and occasionally severe and repeated convulsions. These 
alarming and really dangerous symptoms speedily subside on the 
removal of the cause. One of the most severe attacks of eclamp- 
sia which I have seen occurred in a boy eight or ten years old, 
induced by swallowing the parenchymatous portions of oranges 
which he had been in the habit of eating, and which had accumu- 
lated in the stomach and intestines. The expulsion of the offend- 
ing substance gave immediate relief. 

Sometimes, but not often, the symptoms of acute indigestion 
closely resemble those of pneumonitis. For example, an infant, 
whom I once treated, was seized at night with fever, hurried 
respiration, and the expiratory moan, which some writers consider 
pathognomonic of pneumonitis or pleuritis. These symptoms sub- 
sided when the bowels were freely opened, and currants, which had 
been eaten the previous day, were expelled. 

As the child advances in years and its general health improves, 
the digestive function is less frequently disturbed. After the age 
of three or four years the disease which we are considering becomes 



PROGNOSIS — TREATMENT. 571 

one of much less frequency and importance than in infancy and 
early childhood. 

Indigestion leads to some of the most common and serious affec- 
tions of early life. In the infant, if it continue a considerable time, 
inflammation of the buccal, oesophageal, or gastric mucous mem- 
brane, or of some part of the intestinal tract, ordinarily occurs. In 
the young infant thrush soon makes its appearance, and, whatever 
the age, the cachexia which results from continued indigestion in- 
creases the liability to organic affections. Eclampsia is the most 
serious, and at the same time a frequent, result of temporary or 
acute indigestion. 

Prognosis. — In simple indigestion this is good. It is doubtful 
or unfavorable when ulterior diseases occur, and in proportion to 
their gravity. 

Treatment. — The first indication in treatment is obviously the 
removal of the cause. In acute indigestion, when there is reason 
to believe that there is some offending substance in the stomach 
or intestines, if the symptoms occur soon after the substance is 
taken, an emetic may be administered, and ipecacuanha, in syrup 
or powder, is safe and usually efficient. If several hours have 
elapsed, a purgative should be given, as castor oil, or calomel, 
either alone or in combination with syrup of rhubarb. 

If the symptoms are urgent, especially if convulsions are threat- 
ened, we should not wait for the slow action of a purgative, but 
should resort to enemata to open the bowels. Sometimes the pain 
in acute indigestion is such as to require the use of opiates. In 
the infant there is often an excess of acid in the stomach and in- 
testines, which is best treated by alkaline remedies, as lime-water 
in combination with the opiate. The following mixture will be 
found useful in such cases : — 

R. Tinct. opii, or liq. opii compos, gtt. xij ; 
Magnes. calcinat. gr. xij ; 
Sacch. alb. 3ij ; 
Aq. anisi ^iss. Misce. 
Dose, the bottle being first shaken, one teaspoonful from two to four hours to a 
child a year old. If there is much pain, it is well to add a little chloroform or 
Hoffman's anodyne to the mixture. 

If in the acute indigestion of infants there is diarrhoea, the cam- 
phorated tincture of opium in combination with chalk mixture 
should be given instead of the above, fifteen drops of the one to a 
teaspoonful of the other. Infants whose diet properly consists 
largely of milk, digest with most difficulty the caseum, which is 



572 INDIGESTION. 

apt to pass the bowels in an imperfectly digested state, or to collect 
in a large and firm mass in the stomach, causing gastralgia and 
rendering the child fretful till it is vomited. I have elsewhere re- 
commended as important to prevent these attacks of acute dys- 
pepsia, the use of the upper third of the milk, which contains less 
than the average caseum, and the addition of an alkali to the milk, 
which retards the coagulation till it begins to be acted upon by the 
gastric juice, and tends to prevent the formation of large and firm 
caseous coagula in the stomach. 

In chronic indigestion the means of relief are different. They 
are twofold : first, as regards change of diet ; secondly, measures 
to improve the digestive function. Spoon-fed infants, suffering 
from habitual indigestion, require the utmost care as regards the 
character of their food, its preparation, and the times of feeding. 
Often it is best, if practicable, to procure a wet-nurse, and some- 
times removal to a more salubrious locality is followed at once by 
improvement in the digestive function. If the infant is already 
wet-nursed, the milk should be examined microscopically and 
otherwise, and inquiry should be instituted in reference to the 
health and diet of the wet-nurse. Sometimes a change of wet-nurse 
is advisable. For facts and considerations bearing on this point, 
the reader is referred. to the chapters relating to regimen. 

Infants, as well as children, with chronic indigestion are occa- 
sionally much benefited by the moderate and judicious use of 
alcoholic stimulants. They should be given sparingly with their 
food, and should be discontinued as soon as the digestive function 
is fully restored. M. Donne and some other French writers recom- 
mend the habitual use of wine for infants even in a state of health, 
but there are reasons, moral as well as physical, why alcoholic 
stimulants should only be used as medicines, and never in a state 
of health. 

If the case is one of simple or uncomplicated indigestion, tonics, 
either the mineral or vegetable, may be employed. In many in- 
stances, however, especially in infancy, gastro-intestinal inflamma- 
tion has supervened, and in such cases those tonics should be em- 
ployed which exert a favorable, or, at least, not an unfavorable 
effect on the hypersemic and irritable surface over which they pass. 

When indigestion is simple, or accompanied by no serious com- 
plication, wine of iron, citrate of quinine and iron, and the elixir 
of calisaya bark, may be mentioned among the safe and efficient 
agents to improve the digestive function. The following is also 
a good formula for cases of simple indigestion: — 



TREATMENT. 573 

R. Ferri citrat. gr. xvj ; 

Bismuth, citrat. gr. xlviij ; 
Aquae 3 ij. Misce. 
Dose, one teaspoonful three or four times daily to a child of two or three years. 

The ferruginous preparations are most efficacious in cases which 
are attended by signs of ansernia. 

Among the useful vegetable stomachics and tonics may be men- 
tioned the compound tincture of cinchona, compound tincture of 
gentian, infusion of columbo, fluid extract of columbo, and fluid 
extract of cinchona. 

If chronic indigestion is complicated with gastro-intestinal 
inflammation, subacute or chronic, for this is the form which is 
usually present, there are still certain tonics which may be advan- 
tageously administered. Columbo and the compound tincture of 
cinchona are often useful in these cases, and of the chalybeates 
wine of iron or the tincture ferri chloridi, in small doses, may be 
safely administered. But the remedy which I have found most 
serviceable, both as a tonic and for the inflammatory disease, is 
tincture of columbo in combination with the liquor ferri nitratis, 
given every four hours according to the formula contained in our 
remarks on the treatment of intestinal inflammation. 

I have not alluded to the use of pepsin as a remedial agent in 
indigestion. The theory of its employment in atonic states of the 
stomach is good, but physicians in this country have, in most in- 
stances, failed to observe that benefit from its use which they had 
been led to expect, and which seems to have followed its employ- 
ment in the practice of some of the European physicians. Perhaps 
the result would have been better had fresher and better prepara- 
tions of pepsin been prescribed. Boudault's pepsin from Paris has 
been most used in this country, but ordinarily I believe without 
appreciable benefit. I prescribed it in doses of two or three grains, 
several times daily, to foundlings from one to three months old in 
the Infant's Hospital, but the infants to whom it was given did 
not appear to do better than those from whom it was withheld. 

The American pepsin, prepared under the intelligent supervision 
of Dr. James S. Hawley, can be obtained in the shops in the form 
of a powder and wine. From its freshness and better taste it 
possesses advantages over the French preparations. 

Infants affected with diarrhoea from indigestion I have often 
observed to improve under the use of powders consisting of equal 
parts of subnitrate of bismuth and the American pepsin, but the 
benefit was perhaps more due to the former than the latter agent. 



574 CONGESTION OF THE STOMACH — GASTRITIS. 

An infant of three months can take three grains of each every three 
hours, and one of twelve months six or eight grains. 

Dyspepsia often rapidly disappears hy hygienic measures with- 
out the use of medicines, as hy removal from the city, to the 
country, out-door exercise, or, if the patient is an infant, hy "being 
carried into the open air daily. In infants, also, marked improve- 
ment is often observed on the approach of the cool and bracing 
weather of autumn and winter. 

Congestion of the Stomach. 

Passive congestion of the stomach is described among the dis- 
eases of this organ by Billard ; but it is a pathological state of 
little importance in itself. It occurs in new-born infants, asphyxi- 
ated at birth and with difficulty resuscitated. In these cases there 
is generally intense capillary congestion throughout the system. 
The mucous membrane of the stomach is injected, but not more 
than that of the mouth or intestines. If circulation and respira- 
tion are fully established, this injection of the capillaries subsides. 
~No treatment is required, except measures to promote the circula- 
tory and respiratory functions. In cyanosis and atelectasis there 
is often general congestion of the capillaries of the systemic circu- 
latory system, on account of the obstruction to the now of blood 
through the heart in the one disease and through the lungs in the 
other. There is in these cases passive congestion of the stomach, 
but not more than of the other organs. 

Gastritis. 

Inflammation of the stomach, except when produced by the 
direct contact of some irritant, is rare in infancy and childhood, 
independently of disease in some other portion of the intestinal 
tract. Gases have, ' however, been reported in which it was not 
known that any irritating ingesta had been taken, and in which a 
careful examination revealed a healthy or nearly healthy state of 
other portions of the digestive tube. The subjects were, for the 
most part, young infants. The following is an example related by 
Billard:— 

An infant, four days old, remarkable for the color of his face 
and firmness of flesh, refused the breast and vomited yellow, acid 
matter. On the following day the vomiting had increased, the legs 
were oedematous, face pale and pinched, respiration difficult, skin 
cold, pulse slow and irregular, and pressure on the epigastric region 
produced cries indicative of pain. 



CAUSES. biO 

Third day: general sinking; face thin and expressive of great 
pain ; stools natural. 

Fourth and fifth days : condition the same. Death occurred on 
the sixth day, and the autopsy was made on the day following. 

With the exception of slight pneumonitis, no disease was dis- 
covered in any part of the system besides the stomach. The 
mucous membrane of this organ was intensely vascular near the 
cardiac orifice and along the lesser curvature. It was also tume- 
fied, and could be easily raised with the nail. In the remainder 
of this organ there was strongly-marked capilliform injection. 

This case is interesting as showing what may happen, though 
rarely. A nursing infant is seized with gastritis without appa- 
rently having taken any irritating ingesta, and without other dis- 
ease of the digestive apparatus. It is probable, however, that, in 
cases like the above, the cause, if ascertained, would be found in 
the ingesta: perhaps drinks too hot, perhaps elements of colos- 
trum, or pathological elements in the milk, which might produce 
gastritis in young infants in whom the mucous membrane is deli- 
cate and sensitive. 

Gastritis is not uncommon in infancy in connection with inflam- 
mation of the intestines. The latter inflammation is sometimes 
apparently subordinate to the former, and, if such patients die, the 
fatal result is due mainly to the gastric disease. 

Causes. — Gastritis as I have observed it in infants has been 
in most cases due in great part to the continued use of improper 
food, of food not suitable to the age of the child, and which was, 
therefore, with difficulty digested. Milk, acid or otherwise un- 
wholesome, farinaceous substances, stale or of an inferior quality 
and not properly prepared, drinks too hot or too cold, may be 
specified among the causes. Therefore, this disease is most com- 
mon in bottle-fed infants, and is comparatively rare in those who 
receive abundant and wholesome breast milk. Anti-hygienic 
agencies, apart from the diet, no doubt exert some influence in the 
production of gastritis, as they do of stomatitis. Uncleanliness, 
residence in damp and dark apartments, and in an atmosphere 
loaded with noxious gases, produce a condition of system which 
strongly predisposes to these inflammations, if, indeed, they may 
not be enumerated among the direct causes. 

Eilliet and Barthez have called attention to the fact that certain 
medicinal substances given to children occasionally cause gastritis. 
They have observed this effect from the use of tartar emetic, 
Kermes mineral, and croton oil. Gastritis occurring in this way 



576 GASTRITIS. 

may or may not be associated with inflammation in contiguous 
portions of the digestive tube. Elsewhere I have related a case 
in which gastro-enteritis occurred in a child nine years old, after 
having taken a considerable quantity of kerosene oil for spasmodic 
croup. 

Inflammation of the stomach is thought by some to accompany 
measles and scarlet fever during the eruptive period, though the 
proof of this is not decisive. If it occur, it corresponds with the 
stomatitis and cutaneous inflammation of those diseases, and dis- 
appears as they subside. It is mild, and accompanied by few 
symptoms. I have, however, already stated, in the remarks on 
scarlet fever, that I have in a few instances examined the stomachs 
of those who had died during the eruptive period of these diseases, 
and found them free from any appreciable inflammatory lesion. 

Age. — From the records of about seventy cases of inflammatory 
disease of the digestive mucous membrane which I have preserved, 
it appears that gastritis is rare over the age of six months. On 
the other hand, it is not uncommon in infants under the age of 
three months who are deprived of the breast milk. I have met 
it chiefly in foundlings fed with the bottle, and having at the 
same time entero-colitis and often also stomatitis and oesophagitis. 
In these cases there is sometimes continuous or almost continuous 
injection and thickening of the mucous membrane, from the lips to 
near the pyloric orifice of the stomach and even beyond this orifice 
in the intestines. The following is an example of gastritis as it 
frequently occurs in foundling institutions : — 

Case. — R.W., female, two weeks old, was admitted into the New York 
Infant Asylum, August 24th, 1865, anaemic and somewhat emaciated. It 
was in part wet-nursed, and in part bottle-fed. The emaciation increased, 
and nearly the entire buccal cavity became covered with the confer void 
growth of thrush. On September 4th, diarrhoea commenced. Borax 
was used for the mouth, and alkalies and astringents to check the diar- 
rhoea, but without material improvement. 

The following was the record for September 7th : " Cries almost con- 
stantly, with feeble or whining voice ; still has thrush ; nurses and does 
not vomit ; dejections five or six daily, and green ; pulse 136, feeble." 
Death occurred September 8th. 

Autopsy September dth. — Mouth and fauces not examined; mucous 
membrane of oesophagus vascular in its whole extent, with slight thicken- 
ing, but without ulceration ; mucous membrane of stomach injected like 
that of the oesophagus, and somewhat thickened, except in its pyloric 
extremity, where the appearance was natural, or nearly so ; the color in 
the central part of the inflamed gastric membrane was deep red ; no 
thrush was noticed, except on the buccal surface during life ; along the 
great curvature of the stomach were white flakes, resembling those of 
thrush, but which were found by the microscope to consist mainly of 



SYMPTOMS — ANATOMICAL CHARACTERS. 577 

oil globules and epithelial cells, without the cryptogamic formation ; 
mucous membrane of small intestines healthy in their whole extent, ex- 
cept slightly increased vascularit}' in a few places in the ileum ; mucous 
membrane of colon much injected throughout, except near the ileo-esecal 
valve, where the vascularity was slight ; in the transverse and descend- 
ing colon, the redness was pretty uniform, and the membrane was 
thickened, but not ulcerated ; solitary glands and Peyer's patches some- 
what elevated. 

The observations of Yalleix show how frequently gastritis is 
associated with severe attacks of thrush. In twenty-three of his 
eases of the latter disease, in wliieh the condition of the stomach 
was noted after death, this organ presented inflammatory lesions 
in seventeen, and in three others appearances which may or may 
not have been due to inflammation. 

Symptoms. — A difficulty exists in isolating and defining the 
symptoms of gastritis from the fact that it commonly coexists 
with other inflammation of the digestive tube. Though we may 
never be able to diagnosticate this affection as certainly as we can 
croup or pneumonitis, still, there are symptoms which arise directly 
from the gastritis, and with care we may be able to distinguish 
them from those symptoms which are clue to other pathological 
states. 

If gastritis is acute, pain is present. In the above case from 
Billard, as well as in a case observed by myself, and related under 
the head of gelatinous softening, there were frequent cries, and the 
countenance indicated much suffering, until the stage of collapse. 
If there is less intensity of inflammation, and the disease is more 
protracted, as is ordinarily the case, the pain is not so severe, and 
it may be so slight as not to attract attention. Sometimes there 
is tenderness, so that pressure Upon the epigastric region is badly 
tolerated. Vomiting is regarded as one of the most constant 
symptoms. The infant after nursing seems in distress till the 
milk is returned, but it nurses with avidity in consequence of the 
thirst, if it is not too exhausted or feeble. The dejections may be 
quite regular throughout the disease, as in the case from Billard. 
There is ordinarily, however, diarrhoea from the presence of entero- 
colitis. The pulse is sometimes accelerated, and sometimes nearly 
natural. The emaciation in gastritis is rapid, since not only the 
milk is in great measure vomited, but the digestive function, so far 
as the stomach is concerned, is seriously impaired. The features 
become wrinkled and senile, the eyes hollow, the limbs attenuated r 
and the cranial bones uneven. Death occurs from exhaustion. 

Anatomical Characters. — Simple gastritis may affect the 
37 



578 GASTEITIS. 

entire mucous surface of the stomach, or be limited to a certain 
part. The part which is most likely to escape is that towards 
the pyloric orifice. This portion of the organ is sometimes found 
in nearly or quite the normal state, while the cardiac half or two- 
thirds are inflamed. The vascularity of the diseased surface is not 
uniform. In one place there is simple arborescence ; in another 
intense continuous redness, and between these two extremes are 
different grades of vascularity. The mucous membrane is some- 
what thickened, softened, and the secretion of mucus increased. 
Extravasation of blood is not infrequent under the mucous mem- 
brane, usually in points, and the mucus may be mixed with more 
or less blood. Small shreds or portions of coagulated milk are 
often found with the mucus attached to the gastric surface. I 
have observed, though rarely, small superficial ulcers at the point 
where the inflammation had been most intense. 

Diagnosis. — In protracted cases, when entero-colitis is present, 
it is difficult to make a positive diagnosis. Our opinion must 
then be little more than a plausible conjecture. In the acute 
attacks we can diagnosticate the gastritis with more certainty. 
If a young infant affected with thrush is seized with pain, and it 
vomits often ; if emaciation is rapid, and there is no diarrhoea, or 
diarrhoea not sufficient to account for the prostration ; if the buccal 
mucous membrane, dotted with the points of thrush, presents a dry 
appearance and the deep red color of severe stomatitis, there can 
be little doubt of the presence of gastritis. The diagnosis is 
rendered more certain by signs of tenderness, when pressure is 
made upon the epigastric region. 

Prognosis. — Like other inflammations, gastritis is probably 
sometimes so mild that it does not' materially increase the suffering 
or danger of the child. This mild form of the disease Under 
favorable circumstances soon subsides. In other cases, by the con- 
tinuance or increase of the cause, the inflammatory process becomes 
more severe and extensive, resulting even in disintegration of the 
mucous membrane. Those cases are especially severe and likely 
to terminate fatally, which are protracted and accompanied by 
severe thrush, with a desiccated appearance of the mouth, or with 
entero-colitis. Pain, vomiting, and rapid emaciation in such chil- 
dren indicate the speedy approach of death. Improvement in the 
stomatitis or entero-colitis is a favorable indication, but these in- 
flammations may improve without corresponding improvement in 
the gastritis. 

Treatment. — All food or drinks, except those of a bland and 



FOLLICULAR GASTRITIS. 579 

Tmirritating nature, should be forbidden. If practicable, the 
young infant should take no nutriment except the mother's milk 
or that of a wet-nurse. As there is an excess of acid in inflam- 
mation of the mucous coat of the digestive tube, lime-water may 
be advantageously given in combination with the breast milk. 
Opium is required to relieve the pain and quiet the action of the 
stomach. The camphorated tincture of opium, in doses of four or 
five drops to a child a month old, or the syrup of poppy, tincture 
of opium, or liquor opii compositus, in proportionate doses, may be 
administered. If there is thirst, a little gum- water should be 
given frequently. If there is much emaciation and the vital 
powers are failing, it will be necessary to resort to the use of 
stimulants. Stimulating enemata are preferable to stimulants 
given by the mouth. Much benefit may be anticipated from 
local measures. Irritation should be produced upon the epigas- 
trium by mustard or other means, followed by fomentations. It 
is rarely, perhaps never, proper to use leeches, if the patient be a 
young infant. Death occurs from exhaustion, and it is, therefore, 
important that the vital powers should not be reduced. If the 
child is weaned, the diet at first should be restricted to arrowroot, 
rice-water, barley-water, or similar bland substances. In advanced 
stages of gastritis, animal broths and jellies may be required. 

Follicular Gastritis— Diphtheritic Gastritis. 

The pathological character of follicular gastritis is similar to 
that of follicular stomatitis. It is an inflammation affecting the 
gastric follicles and ending in their ulceration. It is not a fre- 
quent disease ; it occurs in young infants. Billard observed fifteen 
cases. The symptoms in these patients were similar to those in 
simple gastritis of a severe form. The emaciation and prostration 
were rapid, and death occurred early. We can only diagnosticate 
the gastritis without determining its follicular character. How 
many recover it is impossible to ascertain, but the disease is apt to 
be fatal on account of the intensity of the inflammation, not only 
of the follicles but of the intervening mucous membrane. The 
treatment is that of gastritis. 

Diphtheritic gastritis is infrequent. It occasionally occurs 
during epidemics of diphtheria. Allusion is elsewhere made to a 
case treated in the Nursery and Child's Hospital of this city, in 
December, 1859. The patient, eighteen months old, previously 
had had protracted entero-colitis, and died exhausted after a brief 
attack of diphtheria. There were lesions referable to the entero- 



f)80 SOFTENING. 

colitis, and the body was much emaciated. The diphtheritic exu- 
dation was found covering the fauces, epiglottis, glottis, to the 
rima glottidis, the entire oesophagus, and almost the entire stomach. 
The mucous surface underneath was injected ; that of the oeso- 
phagus and stomach especially was very vascular, softened and 
thickened, and the submucous connective tissue was infiltrated. 

The pseudo-membrane, taken from the epiglottis and examined 
under the microscope, presented an amorphous appearance : no cells 
were noticed in it, and fibrillation was not distinct ; that from the 
stomach was found to consist almost entirely of cells, the plastic 
corpuscles of some writers, the pyoid of others. The digestive 
process, so far as the stomach was concerned, had evidently been 
almost if not entirely suspended, and hence in part the sudden 
prostration. Diphtheritic gastritis is but a local manifestation of 
a grave constitutional disease. 

Post-Mortem Digestion, Softening. 

It is now many years since the attention of the profession was 
directed to disorganization of the coats of the stomach, which is 
sometimes observed at post-mortem examinations. John Hunter 
first ascertained that the gastric juice begins to have a solvent 
effect on the tissues of the stomach soon after death. Though 
Hunter erred, when he stated that the coats of the stomach are 
more or less digested in all or nearly all cases, it is certain that 
post-mortem digestion does take place in many cadavers, so that a 
few hours after death the gastric mucous membrane is destroyed 
to a greater or less extent, and occasionally the stomach is perfo- 
rated or is even severed from its connection with the oesophagus. 
I have seen several examples of this post-mortem perforation in 
infants. 

Some of the cases of supposed pathological softening of the 
stomach reported by the older observers, seem to have been such 
as I have described, namely, cadaveric. Yet there are two other 
kinds of softening occurring in children, which are strictly patho- 
logical, the one designated white, the other, by Cruveilhier, gela- 
tinous. 

White softening of the gastro-intestinal mucous membrane 
results from deficient alimentation. It has been observed only 
in anaemic and ill-nourished children. The mucous membrane in 
such loses its firmness, and is easily separated from the subjacent 
tissue. This disorganization has no connection with any inflam- 
matory process. It is simply a disintegration of the mucous 



ITS NATURE. 581 

membrane in consequence of the low vitality of the patient, 
whether or not there are co-operating causes. I believe that, in 
a large proportion of infants whose systems have been reduced 
and blood impoverished for a considerable time, the gastrointes- 
tinal mucous membrane will be found after death less firm and 
resisting than in those who have been habitually robust. 

A vague opinion. exists in the minds of most physicians as to the 
nature and even appearance of the so-called gelatinous softening of 
the stomach, and the following observations will be cited in order 
to give a clearer idea of it. 

Billard has recorded two cases with his usual minuteness, and 
adds: "What inference shall be drawn from the preceding facts 
and considerations? None other than that the gelatinous softening 
of the stomach consists in a disorganization of the mucous mem- 
brane of this viscus, caused by an acute or chronic phlegmasia; 
that this disorganization is characterized by an accumulation of 
serum in the walls of this organ ; the intumescence and gelatinous 
consistence of the mucous membrane in a part usually circum- 
scribed, situated more frequently in the greater curvature, and 
about which the membrane exhibits more or less evident traces of 
an acute or chronic phlegmasia. . . . The softening now under 
consideration must not be confounded with another kind of soften- 
ing" (white) " which does not usually succeed an acute phlegmasia." 

Billard believes that, while gelatinous softening results from 
inflammation of the mucous membrane, its proximate cause is an 
afflux of serum to the part in which the disorganization occurs. 
In one of the two cases which he reports, he thinks that the in- 
flammation was acute, but in the other chronic, and, therefore, 
presenting less vascularity. 

West, in speaking of gelatinous softening, says : " Softening of 
the stomach varies in degree from a slight diminution in the con- 
sistence of the mucous membrane, to a state of complete difflu- 
ence of all the tissues of the organ. . . . When the change is not 
far advanced, the exterior of the stomach presents a perfectly 
natural appearance, but on laying it open a colorless or slightly 
brownish tenacious mucus, like the mucilage of quince-seeds, is 
found closely adhering to its interior, over a more or less consider- 
able space at the great end of this organ." 

Cruveilhier says: "This softening often proceeds from the 
interior towards the exterior. There is at the beginning simple 
separation of the fibres by a gelatinous mucus, and in consequence 
the parietes are thickened and semi-transparent. ... If the trans- 



582 SOFTENING. 

formation be complete, the disorganized portions are removed layer 
after layer, those which remain becoming gradually thinner. The 
peritoneum alone resists for some time, but at length it is attacked, 
worn, and gives way, and perforation of the stomach results. The 
parts thus transformed are colorless, transparent, apparently inor- 
ganic, completely deprived of vessels, and exhaling an odor re- 
sembling that of milk." 

Bouchut remarks : " Softening of the mucous membrane of the 
stomach in children at the breast is not a special disease which it 
is necessary to describe by itself. This alteration is always con- 
nected with other diseases, and is especially with disease of the 
large intestine, the knowledge of which fact has been too long 
neglected. It is the consequence of the acidity of the liquids 
contained in the digestive tube of young children, liquids which 
are very acid in the disease we have above referred to." 

Dr. Carswell states that there is a pathological softening of the 
mucous membrane of the stomach, and that when it occurs the 
symptoms may be those of gastritis or enteritis. 

Rokitansky says of this form of softening : " If we consider, in 
addition to the above remarks, the uniform localization of the 
disease, that in none of its stages it presents, either at the point of 
the softening or in its vicinity, hypersemic injection or reddening, 
and that we are still less able to demonstrate upon the inner surface 
of the stomach or in the tissue of its coats the products of inflam- 
mation, we are constrained to infer the non-inflammatory nature 
of the affection." 

"Without extending these extracts, it is seen that eminent au- 
thorities not only disagree in reference to the cause of gelatinous 
softening of the stomach, but that they also differ in their descrip- 
tion of its appearance. This diversity of opinion is most likely 
attributable to the fact that the two kinds of softening have been 
confounded. Rokitansky and Bouchut probably refer to cases of 
white softening, which occurs in atonic state of the tissues in 
feeble infants, and, therefore, have concluded that softening of the 
stomach is not inflammatory. I believe, from my observations, that 
the opinion of Billard is correct, and that true gelatinous softening 
is the result of gastric inflammation, sometimes chronic, sometimes 
acute. But I have seen appearances which led me to think that 
the immediate causes of the softening continue to operate after 
death, so that its amount is less at the time of death than a few 
hours subsequently. 

The following case, which was watched by myself with great 



case. 583 

interest from beginning to end, is an example of inflammatory 
softening : — 

Case. — G. S., male, robust, was born July 10th, 1865. The mother not 
being able to suckle the infant, and the danger of artificial feeding in the 
warm months being well understood, a wet-nurse was procured. About 
the 14th of July, this wet-nurse having insufficient milk, another was pro- 
cured temporarily, who suckled the infant till July 20th, when a third 
wet-nurse was engaged, whose child, healthy and thriving, was six weeks 
old. Previously to this time the infant appeared well. It had uniformly 
nursed vigorously and seemed satisfied. 

On the 22d of Juty, thrush, apparently mild, was observed in the 
mouth, and a powder, supposed to be borax, and labelled such, was 
obtained at a drug store, to be used as a wash for the mouth. This 
powder was afterward ascertained to be alum. About five grains were 
dissolved in as many teaspoonfuls of water, and the mouth of the child 
was swabbed occasionally with it. A piece of linen, folded so as to 
resemble the tip of a nursing bottle, was occasionally dipped into the 
solution, and the infant was allowed to suck it. The use of the alum 
was commenced about 6 P.M. In the first part of the evening the infant 
slept considerably, and of course did not nurse often, but about 8 P.M. 
it began to be very fretful, and it then nursed more frequently. It 
vomited once between 8 and 10 o'clock P.M. In order to quiet the 
infant, the tip soaked in the solution was often applied to the mouth, 
but there was scarcely any intermission in its crying. Through the 
night it vomited again once or twice, and about the middle of the night 
had one free liquid stool, which was passed with much tenesmus. The 
countenance of the infant was indicative of suffering, and its thighs were 
repeatedly flexed over the abdomen, as if that were the seat of its dis- 
tress. Paregoric in two-drop doses was several times given through 
the night, and flannel soaked with hot whiskey was applied to the 
abdomen. 

July 23d. In ignorance of the cause of the child's sickness, another 
wet-nurse was obtained early in the morning, and one-sixth of a drop 
of liq. opii compos, was given every hour, with the effect of inducing a 
little sleep. The tongue was very red, desiccated, and studded with 
more numerous points of thrush than on the previous day. It now 
refused to nurse, apparently from soreness of the tongue. At each 
attempt of the nurse to induce it to take the nipple, it rubbed the mouth 
across the breast, crying either from pain or disappointment. The alum 
was not used in the latter part of the night of the 22d, but late in the 
morning of the 23d it was resumed, the mistake of the druggist not 
being discovered till midday, when it was estimated that about five 
grains had been used. Occasional^ a little of the solution was placed 
in the mouth with a spoon so as to be swallowed, in the belief that the 
thrush affected the oesophagus. The infant continued to suffer much 
during the day, sleeping at times a few minutes. Its strength was evi- 
dently failing; its respiration regular; pulse about 140; its alvine dis- 
charges yellow, of natural consistence and frequency. 

Evening, 23d. Surface hot; is very restless; pulse 150 to 160 ; tongue 
dry, intensely red, and dotted with points of thrush. Is treated with 
opiates, a little lime-water, and fomentations. 

24th. In the first part of the day, nursed pretty well; in the latter 
part, could be induced to draw the breast only once or twice. The 



584 SOFTENING. 

symptoms to-day were the same as yesterday, with the exception of 
greater emaciation and prostration; cranial bones uneven, and features 
pinched. 

25th. Pulse 140 to 148; strength rapidly failing, but it cries at times 
loudly. The milk of the nurse, placed in the mouth with a spoon, is 
often held a considerable time before it is swallowed, and deglutition 
seems difficult. Respiration in the first part of the day and previously, 
natural; in the latter part of the day, accelerated ; dejections natural; 
no vomiting ; appearance of tongue more natural than yesterday. 

26th. Died to-day in a state of collapse at 12^ P.M. The hands 
were cold several hours before death, and the milk given it was regur- 
gitated. 

Autopsy twenty-two hours after death. — Much emaciation ; no rigor 
mortis; cranial bones uneven; upper part of the pharynx injected to 
the extent of about half an inch; but from this point to the stomach 
membrane healthy; mucous membrane covering the cardiac two-thirds 
of the stomach disintegrated, almost diffluent, and in places detached 
from the subjacent tissue; mucous coat of the pyloric third of the organ 
nearly healthy; along the edge of the softened portion the mucous 
membrane was vascular to the extent of a few lines ; the muscular and 
serous coats of the stomach underneath the softened portion were easily 
torn; the mucous membrane of the small intestine presented in places 
that degree of vascularity known as arborescence ; there was no destruc- 
tion or softening of its mucous membrane; the colon was health} 7 ; the 
stomach was nearly empty; the contents of the small and large intestines 
were natural in color and consistence; the other viscera were healthy; 
in the left pleural cavity was about an ounce of transparent serum, and 
a less quantity in the right cavity. 

It cannot be doubted that the softening in the above case was 
pathological. The weather at the time was warm, but the infant 
was placed on ice, and a pan containing ice was kept upon the 
abdomen. This infant died evidently of gastritis, the accompany- 
ing inflammation being subordinate, and in fact insignificant. At 
first it was a question with me, whether the alum might not have 
caused the gastritis, so that the case should be properly placed in 
the category of deaths from swallowing corrosive substances. In 
order to determine this point, I administered alum daily to two 
kittens, commencing when they were seven days old. The quantity 
given to each was ten grains daily in two doses for three consecu- 
tive days, and on the two following days ^lyq grains. The only 
uniform result noticed was an increased flow of saliva, which 
washed some of the alum from their mouths, and occasionally 
slight vomiting. There was not even any apparent inflammation 
of the buccal membrane from the alum. 

Post-mortem appearances as in the above case, and similar ones 
are recorded by Valleix and others, in which gelatinous softening 
coexisted with evident lesions of gastritis, render it highly probable, 



NON-INFLAMMATORY DIARRHOEA. 585 

if indeed they do not demonstrate, that the softening is a result of 
the inflammation at the point where it occurs. 

In Valleix's twenty-four cases of what he terms fatal muguet, 
softening of the mucous membrane of the stomach was one of the 
most common lesions, and at the same time, which is the point of 
interest, there were signs which showed conclusively the presence 
of gastric inflammation. The common coexistence of the lesions 
of gastric inflammation, such as redness and thickening, with 
gelatinous softening of the stomach is certainly most reasonably 
explained on the supposition that the one results from the other. 

I am not prepared to accept nor reject the theory of Billard, that 
the immediate cause of the softening is the afflux of serum, nor 
that of Bouchut, that it is an excess of acid. 

It has been said that M. Baron was able to diagnosticate gela- 
tinous softening. The symptoms are those of the severer forms of 
gastritis. The vomiting, great pain, restlessness, sudden and pro- 
gressive emaciation, and, finally, collapse preceding the fatal result, 
are the symptoms on which the diagnosis is based. The treatment 
should be directed to the gastritis. 



CHAPTER VII. 
DIARRHCEA. 

Diarrh(ea is frequent during the whole period of infancy. The 
French writers describe several varieties according to the character 
of the evacuations, as acescent, mucous, and serous. M. Rostan 
even describes fourteen distinct kinds. But the tendency of medi- 
cal science in these modern times is to simplify the nomenclature 
of diseases — to describe under a single name those affections which 
are essentially the same though differing somewhat in their features. 
Now, all the forms of diarrhoea in the infant may be so grouped as 
to reduce the number to not more than three or four. In this 
way repetition and prolixity are avoided, as well as an unnecessary 
refinement. 

Non-Inflammatory Diarrhoea. 

The most common and the simplest form of diarrhoea is that 
enunciated in our heading. Though attended often by an ana- 



586 NON-INFLAMMATORY DIARRHOEA. 

tomical alteration in the intestines, the inflammatory character is 
absent. This disease is described by some writers as simple, or 
catarrrhal, or spasmodic diarrhoea. Many cases of diarrhoea sup- 
posed to be non-inflammatory are really cases of entero-colitis, and 
very frequently diarrhoea not inflammatory in its commencement 
changes its character and becomes such. This is especially true of 
such diarrhoeal affections as are produced by improper diet. 

Causes. — The causes of non-inflammatory diarrhoea are various. 
Influences, which in the adult would have no appreciable effect, 
increase the number of evacuations in the infant. 

A common cause is food of unsuitable quality or quantity. Food 
that does not digest well is apt to stimulate the intestinal follicles 
to excessive secretion and accelerate the peristaltic action of the 
intestines. In infants diarrhoea is sometimes due to too frequent 
feeding. Many whose stomachs are overloaded obtain relief by 
vomiting, but others do not. The food not needed for nutrition 
serves as an irritant, and produces green and unhealthy evacua- 
tions. Dr. James Jackson, in his letters to a young physician, 
calls attention to this cause of diarrhoea. 

The mother's milk or the milk of the wet-nurse may disagree, 
either from some temporary derangement of her system, or con- 
tinued ill-health, or from causes which are not understood. Non- 
inflammatory diarrhoea in the nursling is the immediate result, but 
inflammation may afterwards occur. The milk in these cases fre- 
quently contains the elements of colostrum. 

Fright or strong mental impressions will also in some children 
increase the number of evacuations. This cause being transient, 
the diarrhoea soon subsides. 

Another cause is exposure to cold. Children who are insuffi- 
ciently clothed in the winter season, who are taken from a heated 
room into a cool one without sufficient precaution, or who lie un- 
covered at night, are very subject to diarrhoeal attacks from the 
impression of cold on the system. 

The cause of non-inflammatory diarrhoea may exist in the child 
itself. In some children the evolution of the teeth is attended by 
a relaxed state of the bowels, which ceases when the gum is pierced. 
"Worms in the intestines may also operate as a cause. Diarrhoea is 
occasionally salutary within certain limits, and of course it is not 
strictly correct to call it a disease when it is a means of relief. If 
occurring from an excess of food or from dentition, it may prevent 
convulsive seizures. 



SYMPTOMS. 587 

Symptoms. — Non-inflammatory diarrhoea may come on suddenly ; 
but at other times there are precursory symptoms continuing for 
some days. Whether or not there are antecedent symptoms de- 
pends chiefly on the cause. If diarrhoea occur from fright, or from 
cold, or from improper aliment, it commonly occurs immediately. 
If from painful dentition, there are previous symptoms referable 
to the eruption of the teeth. 

The prodromic symptoms are restlessness and disturbed sleep ; 
sometimes the physiognomy indicates transient abdominal pains. 
Indigestion, characterized by regurgitation, nausea, or even vomit- 
ing, is an occasional premonitory condition. Finally, diarrhoea 
commences. The evacuations differ much in color and consistence 
in different cases, and perhaps at different periods in the same case. 
In infants they are apt to be green. This color, which is a source 
of anxiety to the inexperienced, and especially to the parents, is 
often produced by trivial causes. Slight indigestion will produce 
it. So will excess of food, even the most bland and unirritating. 
Occasionally the stools consist in part of undigested portions of 
food, especially the casein. In children advanced beyond the period 
of first dentition the evacuations do not differ materially in ap- 
pearance from those occurring in the adult. The stools are usually 
passed easily, but there is sometimes in infants more or less tenes- 
mus, if they are acid or in any way irritating. Occasionally there 
is a sensation of fulness in the abdomen. 

In the form of diarrhoea which has been designated acescent, not 
only is there an acid odor and reaction of the matter vomited, but 
also of the stools. At night, since less nutriment is taken, and the 
patient is more quiet, the evacuations in non-inflammatory diar- 
rhoea are less frequent than in the daytime. If the complaint is 
slight, there is little desire for drink, but if the stools are frequent 
and thin, especially if they approach the serous character, thirst is 
often intense; the appetite varies; the tongue is moist, and covered 
with a light fur ; there is often more or less meteorism, but no 
abdominal tenderness. 

The face in this disease is pale. In a few days if the evacua- 
tions continue, there is evident loss of weight and flesh. The 
rotundity of the limbs is gradually lost, and the tissues become 
soft and flabby. But in most cases, when the affection has reached 
this stage, its original character is lost, and it has become inflam- 
matory. 

There is no constant fever in true non-inflammatory diarrhoea. 



588 NON-INFLAMMATORY DIARRHCEA. 

Sometimes the pulse is accelerated in the latter part of the day, 
but usually only for a short time. 

Certain epiphenomena, as Barrier terms them, occur at times in 
non-inflammatory as well as in inflammatory diarrhoea, for example 
a sympathetic cough, or, which is more serious, cerebral compli- 
cations. Convulsions or stupor, indicating the supervention of 
spurious hydrocephalus, may occur in either form of diarrhoea. 
This disease is described elsewhere. 

Anatomical Characters. — The structural changes observed in 
the intestines in those who die of non-inflammatory diarrhoea have 
been well described by Billard. "I have seen," says he, "isolated 
follicles, and follicular plexuses of the intestinal tube, in consider- 
able numbers, and developed without being inflamed, in twelve 
infants. There were three aged from eight days to three weeks ; 
two aged two months ; the remaining seven were from nine months 
to one year. The follicles appear at the commencement of denti- 
tion. Ten of these children were affected with diarrhoea of liquid, 
white, mucous matters. This is really the serous diarrhoea of au- 
thors ; and every symptom leads to the belief that there is a direct 
relation between the development of these follicles and the aug- 
mentation of their secretion." . . . "I do not consider this morbid 
development of the muciparous follicles as a true inflammation. 
Nevertheless, this state of excitability which causes the augmenta- 
tion of their secretion is, as it were, an intermediate stage between 
the normal state and the state of inflammation." Barrier's views 
also coincide, in the main, with those of Billard. 

One of the most common lesions observed in the intestines, in 
those who have died with non-inflammatory diarrhoea, is, as these 
authors remark, turgescence of the intestinal glands. In a large 
proportion of cases these glands will be found more distinct than 
in the healthy state. 

The solitary follicles of the large intestines, especially, are, in 
most cases, elevated, and their central depression distinct ; the 
patches of Peyer are also prominent. 

The following is an example of non-inflammatory diarrhoea in a 
young infant : — 

On the 7th of July, 1865, a foundling, one month old, died at 
the Infant Asylum. It was much emaciated, with eyes sunken 
and features pinched, at the time of its death. It was wet-nursed 
towards the close of its life, but the nurse's milk was insufficient. 
It did not vomit ; did not have any marked acceleration of pulse 
(128 per minute), and its evacuations were about four daily, and 



DIAGNOSIS — PROGNOSIS. 589 

thin. The stomach and intestines were pale throughout. The 
solitary glands, particularly those in the colon, and the patches of 
Peyer, were tumefied so as to he visible, and somewhat raised above 
the surrounding surface. There was probably slight thickening 
of the mucous membrane, and tumefaction of the muciparous 
follicles, but these changes were not clearly ascertained. 

Diagnosis. — The only disease with which there is liability of 
confounding non-inflammatory diarrhoea is enteritis or entero- 
colitis. From these it may be diagnosticated by the absence of 
continued fever and of abdominal tenderness. Sometimes, indeed, 
it is difficult to say whether the case is non-inflammatory or 
whether there exists a moderate degree of inflammation, though 
practically the determination of this point is not important. 

Prognosis. — In a large proportion of cases, non-inflammatory 
diarrhoea is not dangerous. With the adoption of suitable mea- 
sures to remove the cause, and the use of medicines to control the 
discharges, the patient recovers. The remark already made may 
be repeated here, that occasionally diarrhoea is salutary within cer- 
tain limits, as when there is a foreign substance in the intestines, 
either irritating mechanically or by its chemical properties, and 
which the diarrhoea serves to remove. 

The danger, in non-inflammatory diarrhoea, arises from compli- 
cations, as spurious hydrocephalus, or from the emaciation and 
exhaustion. There may also be danger of its eventuating in inflam- 
mation, which is always serious. Whether or not the diarrhoea is 
in itself injurious to the child, and a source of danger, may be de- 
termined by observing whether or not there is emaciation. 

If the rotundity of the figure and firmness of the tissues are 
preserved, showing that alimentation is still sufficient, and no com- 
plication arises, the diarrhoea is not as a rule injurious. In infants 
that over-nurse and do not vomit the surplus milk, the evacuations 
are sometimes green and frequent, and yet fulness of figure is pre- 
served, and the development of the body proceeds as usual. The 
same state is sometimes observed in the diarrhoea accompanying 
dentition. In these instances a moderately relaxed state of the 
bowels is not injurious. On the other hand, diarrhoea attended by 
emaciation or softness or flabbiness of the flesh requires immediate 
treatment. Many lives are lost by the neglect of such patients 
till they are so reduced that they can no longer derive any material 
benefit from remedial measures. This fatal neglect is common 
during the process of dentition. 



590 NON-INFLAMMATORY DIARRHG3A. 

Treatment. — It is necessary, in order to treat successfully diar- 
rhoea in infancy and childhood, to ascertain the cause, and, so far 
as possible, to remove it. It is not till the cause ceases to operate, 
that we can expect a satisfactory result from medication. The 
disease may be temporarily relieved by medicine, but it usually 
returns at once when treatment is omitted, unless the patient is 
removed from the influence of the agencies which produce it. 
These remarks are especially applicable to the diarrhoea of infants. 
With them very generally, when affected with this complaint, 
there is some fault as regards the quantity or quality of food. At- 
tention to this matter will show the need of a change of wet-nurse, 
or, if the infant be spoon-fed, a change in the character of its food 
or the mode of preparation or even in the quantity given. In 
many cases, by change in the diet, and the adoption of hygienic 
measures, the complaint ceases, so as to require no medication. If 
medicines are needed, and the symptoms are not urgent, it is occa- 
sionally advantageous to commence treatment by the use of some 
of the milder purgatives in small doses. In the infant, in whom 
the dejections are so generally acid, an alkaline laxative, or a laxa- 
tive conjoined with an alkali, often has a good effect as preliminary 
treatment. Half a teaspoonful to one teaspoonful of castor oil, or 
a proportionate dose of Rochelle salts, removes any acid or irri- 
tating substance from the intestines, and is followed by a diminution 
in the number of stools. The improvement, however, without 
subsequent treatment, is usually only for a day or two. The use 
of a purgative should, therefore, be considered as preliminary to 
other measures. In this city a purgative dose of castor oil is often 
given as a domestic remedy in infantile diarrhoea, the beneficial 
effect from it having popularized its use for this purpose. Trous- 
seau usually gave Kocnelle salts. 

If there has been previous constipation, and the diarrhoea has 
just commenced, a purgative is obviously indicated. "With the 
operation of this medicine there is frequently marked improve- 
ment. West says: "Provided there be neither much pain nor 
much tenesmus, and the evacuations, though watery, are faecal, and 
contain little mucus and no blood, very small doses of the sulphate 
of magnesia and tincture of rhubarb have seemed to me more 
useful than any other remedy: — 

R. Magnesise sulpkatis 5j ; 

Tinct. rhei 3j ; 

Syr. zingiberis gj ; 

Aquae carui 5ix« Misce. 
3j ter die for children one year old ; 



TREATMENT. 591 

and I seldom fail to observe from it a speedy diminution in the 
frequency of the action of the bowels, and a return of the natural 
character of the evacuations." 

In diarrhoea of infants, due to indigestion, and attended by 
acidity, the following prescription is sometimes useful. By im- 
proving digestion and correcting acidity, it has a beneficial effect 
on the diarrhoea. The cases are, however, in my experience ex- 
ceptional in which this is the proper remedy. 

R. Pulv. ipecacuanhas gr. j.; 
Pulv. rhei gr. ij ; 
Sodse bicarb, gr. iv-vij. Misce. 
Divide in chart. No. xij. One powder every four to six hours to an infant one 
year old. 

The effect of laxative medicines employed for the purpose of 
correcting the functions of the gastro-intestinal surface is uncer- 
tain. If there is no improvement from their use within two or 
three days, they should be omitted. "We must rely on astringents, 
opiates, and, in infants, also on alkalies. If the symptoms are 
urgent, if the evacuations are frequent and exhaustive, these 
agents should be employed from the first. Much harm is often 
done, and precious time lost, by prescribing laxative mixtures 
when opiates and astringents are required. I have known them 
to aggravate the complaint, when, by change of measures, there 
was immediate improvement. The majority of cases of non-in- 
flammatory diarrhoea, at the period when the physician is called, 
are best treated by the use of astringents and opiates exclusivelv, 
proper directions at the same time being given in reference to the 
diet and hygienic management. 

In the diarrhoea of infants the compound powder of chalk and 
opium is an excellent medicine, containing, as it does, an astrin- 
gent with the opiate and alkali. It may be given, in doses of 
three grains, to a child one year old, every three hours. I ordina- 
rily employ it with double its quantity of subnitrate of bismuth, 
and know no better remedy for ordinary cases. The following is 
also an old but useful prescription in the simple diarrhoea of 
infants : — 

R. Tinct. opii camphorat., 
Tinct. catechu, aa 3ij ; 
Mistur. cretse §j. Misce. 
Dose, one teaspoonful every two to four hours to a child one year old. 

If there is no acidity of the evacuation, the following mixture 
will often be found effectual, which is similar to one recommended 
by Dr. West:— 



592 INTESTINAL INFLAMMATION OF INFANCY. 

R . Acid, tannic, gr. xij ; 
Tinct. opii gtt. xij ; 
Tinct. cinnamom. comp. ^ij ; 
Haccli. alb. ^ss ; 
Aq. cinnamom. 5x. Misoe. 
Dose, one teaspoonful every two or three hours, or longer time, according to the 
evacuations. 

Kino, krameria, or logwood may be used in place of the astrin- 
gents mentioned above. If the diarrhoea is due to the feeble 
digestive powers of the patient, and its food is therefore irritating, 
powders of pepsin and subnitrate of bismuth may be employed. 

In the treatment of non-inflammatory diarrhoea occurring in 
infancy, it is rarely necessary to use the mineral astringents, as 
acetate of lead or nitrate of silver. If the patient is not relieved 
by opiates, alkalies, and the vegetable astringents, and by proper 
regimen, in all probability there is inflammation of the intestinal 
mucous membrane. In patients over the age of two or three 
years, simple diarrhoea approaches in character that of the adult, 
and the treatment appropriate for the adult is proper in these 
cases, allowance being made for the difference of age. In infants, 
in whom this disease, if protracted, is very liable to eventuate in 
spurious hydrocephalus, stimulants are often required at an early 
period, on account of the prostration and feeble power of endur- 
ance. 



CHAPTER VIII. 

INTESTINAL INFLAMMATION OF INFANCY. 

It is customary with writers to treat of inflammation of the 
small and large intestines in infancy as a single disease, for the 
following reasons : First, the symptoms of colitis, at this period of 
life, do not ordinarily differ, in any marked degree, from those of 
enteritis. The tormina, tenesmus, and abdominal tenderness, which 
characterize colitis in childhood and adult life, are ordinarily 
lacking, or are not appreciable by the observer; and the muco- 
sanguineous evacuations are oftener absent than present. On 
account of this absence of symptoms, Bouchut says: "Dysentery 
is a very rare disease amongst young children. Its existence 
might even be denied, if it had not been observed at the period 
of some severe epidemics of dysentery." If Bouchut refers, by the 



INTESTINAL INFLAMMATION OF INFANCY. 593 

term dysentery, to the ordinary phenomena of that disease, his 
remark is correct ; but, as regards the lesions, it is erroneous, for 
colitis is not so rare in infancy as his remark implies. Billard, 
after analyzing eighty cases of intestinal inflammation in infants, 
says : " From this calculation, it is evidently very difficult to make 
a correct diagnosis of inflammation of the intestinal tube in suck- 
ing infants, yet it would seem as if the proper signs of enteritis or 
ileitis were the rapid tympanitis of the abdomen, the diarrhoea, 
accompanied with vomiting; while in colitis, diarrhoea alone, 
without tympanitis, is the most frequent." And again: "In con- 
sequence of the impossibility we have found to exist of tracing 
with exactitude the series of symptoms proper to inflammation of 
the different portions of the digestive tube, we shall content our- 
selves with presenting an analytical sketch of the causes, symp- 
toms, and ordinary course of inflammation of the mucous membrane 
of the intestines in general." 

The frequent absence of any pathognomonic symptom or sign, by 
which to determine the exact seat of intestinal inflammation in 
the infant, is admitted by recent observers as well as Billard. 

The second reason why intestinal inflammation in the infant is 
described as a single disease is, that enteritis and colitis are in 
the majority of cases coexistent. This will be seen when we come 
to speak of the anatomical characters. 

I have hesitated in selecting a term for this inflammation. The 
expression inflammatory diarrhoea, used by West, is objection- 
able, because it designates a disease by a symptom when there are 
well-marked lesions. To the expression entero-colitis, employed 
by Bouchut, Meigs, and others, there is this objection, that some- 
times the disease is only enteritis, and sometimes colitis ; whereas 
entero-colitis would imply the presence of both inflammation of the 
small and the large intestines. Barrier uses the expression gastro- 
intestinal inflammation, but in a large proportion of cases gastric 
inflammation is absent. I have treated of gastritis as an indepen- 
dent affection, and it seems proper to exclude it from our descrip- 
tion of the intestinal disease, except as a complication. 

Although I prefer the term intestinal inflammation, I shall use, 
in describing the disease, the expressions inflammatory diarrhoea 
and entero-colitis as synonymous, in order to avoid too frequent 
repetition of words. 

Intestinal inflammation is one of the most common and fatal 
of infantile diseases. It is the great summer epidemic of the 
cities, in this country. Unfortunately for a correct understanding 
38 



594 INTESTINAL INFLAMMATION OF INFANCY. 

of its prevalence and mortality in this city and perhaps elsewhere, 
it is very generally in the summer months when obstinate, and 
especially when fatal, called cholera infantum, although, in its 
symptoms and nature, it is very different from that disease. 

Intestinal inflammation is often a protracted complaint, having 
ordinarily a mild commencement, while the true cholera infantum 
begins abruptly, is characterized by violent symptoms, and rapid 
and extreme exhaustion. The two diseases are, however, often 
associated as cause and effect. 

The 1500 fatal cases of so-called cholera infantum, reported every 
summer in this city, are, with now and then an exception, cases of 
inflammation, generally protracted. In like manner, the excess of 
reported cases of infantile marasmus, in the second half of the 
year, over those reported in the first half, should be added to the 
statistics of intestinal inflammation. This excess, which is noticed 
every year in the mortuary tables of this city, is due mainly to the 
death of those wasted infants who have lingered with entero-colitis 
from the summer months. Their marasmus is simply a result of 
the protracted inflammation. 

Causes. — Inflammatory disease of the intestines in infancy, I 
have said, is chiefly a summer affection — at least, in the cities. 
Occasionally it is observed in the winter, and it is then, when not 
due to error of diet, produced by exposure to cold. Infants who 
are taken from warm to cold rooms, or into the open air, by heed- 
less nurses, or who sleep uncovered at night, are especially liable 
to this disease. Entero-colitis produced by this cause occurs both 
in the country and city. 

In these cases the inflammatory process may not commence sud- 
denly. There is often a premonitory stage of simple diarrhoea, 
the first effect of the impression of cold. Indeed, in a very large 
proportion of cases, whatever the cause, non-inflammatory precedes 
inflammatory diarrhoea. 

The influence of the summer season in the production of this 
disease is forcibly shown by the death statistics of this city. Thus, 
for the five years ending with 1863, there were 6379 deaths reported 
from cholera infantum, and of these all but 166 occurred in the 
months from June to October inclusive. The deaths reported for 
the same years from diarrhoea, dysentery, and inflammation of the 
bowels, were 5914, of which 3919 occurred in the months from 
June to October. Of the 5914, the number under the age of five 
years was 3257. 

Those familiar with the diseases of this city, and especially 



causes. 595 

with the autopsies of infants, will agree that four-fifths of the 
above cases which were reported as cholera infantum or diarrhoea 
were cases of intestinal inflammation. There is no one disease, 
except consumption, so prevalent and fatal in this city as infantile 
entero-colitis during the period of its epidemic occurrence in the 
summer months. 

The epidemic commences about the middle of May. From this 
time there is a gradual increase in the number affected, till the 
months of July and August, when the disease attains its maximum 
prevalence and mortality. During the months of September and 
October, the number of seizures and of deaths gradually abates 
till the epidemic character is lost. It is thus seen that the preva- 
lence of intestinal inflammation of infancy in the city bears a 
close relation to the degree of summer heat. That the high tem- 
perature of summer is not in itself sufficient to produce entero- 
colitis is, however, obvious. In elevated localities in the country 
there may be intense and long-continued heat, and yet in such 
places intestinal inflammation of infants is not common. It is no 
doubt the noxious exhalations from various sources with which 
the atmosphere is loaded, as a consequence of the heat, which 
render the disease so prevalent in certain localities in the summer 
months. The exact character of these exhalations or vapors is not 
fully known, but the following facts are clearly established by 
many observations. 

Entero-colitis prevails most on low grounds near the sea-shore. 
Thus, it is common in many parts of Long Island, on Staten Island, 
and on the flats of "Westchester County. Experienced and observ- 
ing physicians of this city do not send infants affected in the 
summer months with entero-colitis to these localities, but to the 
high grounds west of the Hudson, and to the hilly parts of New 
Jersey, where there is comparative immunity from the disease, and 
recovery is more certain and speedy. 

But the state of atmosphere which is most favorable for the 
development of entero-colitis is found only in the cities. The 
filthy streets containing more or less decaying animal and vege- 
table matter, the crowded and unclean tenement houses, the ne- 
glected privies, the slaughter houses, pig-pens, bone-boiling estab- 
lishments, and the like, are so many sources of the most deleterious 
effluvia, which, inspired by the infant, produce diarrhoea and in- 
testinal inflammation. Those squares of the city where sanitary 
regulations are most neglected are the very ones where the mor- 
tality from this cause is largest. 



596 INTESTINAL INFLAMMATION OF INFANCY. 

In the year 1864 the Citizens' Association of the City of K"ew 
York effected a complete and thorough sanitary inspection of lew 
York island, and it was interesting as well as painful to note the 
facts observed by the inspectors in reference to the prevalence of 
the so-called cholera infantum (chiefly entero-colitis) along the 
streets and in the alleys where the causes of insalubrity were most 
abundant. 

Thus, one inspector says, of this disease, it " has probably con 
signed many more to the grave during the past summer than all 
other diseases in my inspection district. In every case examined, I 
have found it. associated with some well-marked source of insalu- 
brity. Vegetable and animal decomposition has been the most 
prominent cause." Another inspector says of the same disease: 

" It was found between the and avenues, where the street, 

at every visit, was found in an indescribably filthy state, in conse- 
quence of deposits of garbage and slops. This was particularly 
noticed in front of the premises where cholera infantum had oc- 
curred." Such was the uniform testimony of all the inspectors. 
In the tenement houses and in portions of the city occupied by 
the poor, where the sources of insalubrity are most numerous, I 
believe, from personal observation, that a majority of the infants 
are more or less affected with diarrhoea, often of an inflammatory 
character, during the months of July, August, and September. 
In the more salubrious localities of the city, there is less of this 
disease, but even here the liability to it is great, on account of the 
proximity of so many sources of impure air. 

But there is another and an important element in the causation 
of intestinal inflammation in the infant. I refer to the diet. 
Many an infant that now falls a victim would escape the disease, 
but for some fault in the character of its food. Those infants in 
the city who are bottle-fed from birth rarely go through the 
summer without being affected with diarrhoea, and a majority 
of such, if under the age of six months, when the warm weather 
commences, are saved from dangerous if not fatal inflammation 
only by removal to the pure air of the country. 

In the families of the poor the food which is given as a substi- 
tute for the mother's milk is very apt to disagree with the feeble 
digestive powers of the infant. The swill milk, about which so 
much has been said and written, is in common use in this city 
among these people, or has been till recently. This milk, in the 
proportion of its ingredients, and sometimes even in its chemical 
character, is very different from the milk of healthy and well-fed 



causes. 597 

cows of the country. Infants to whom this milk and other im- 
proper articles of diet are given are the first to suffer with diar- 
rhoea as warm weather commences, and finally with entero-colitis. 

It is seen that the causes of intestinal inflammation of infancy 
as it prevails in the cities during the summer are mainly twofold, 
atmospheric and dietetic — an insalubrious state of the air which 
the infant breathes, and unsuitable food. Among the poor of the 
cities, both these causes conspire to produce the diarrhoeal maladies. 
It is easy, then, to see why there is so much intestinal disease and 
so great mortality among the infants of the city poor. Moreover, 
on account of their feeble powers of resistance and endurance they 
are especially liable to be affected by morbific agencies. 

It is a common belief in the profession that dentition is one of 
the chief causes of diarrhoea in the infant, whether inflammatory 
or non-inflammatory. 

There is, indeed, great liability to this disease during the period 
of dental evolution. The following statistics, which were mostly 
collected during my term of service in one of the city dispensaries, 
and which comprise all the cases of diarrhoea under the age of 
about Hve years which were brought into that institution for treat- 
ment during the summer months of my attendance, show the pre- 
ponderance of cases in the time of teething. Most of these cases 
were apparently inflammatory. 

Stage of Dentition. Xo. of Cases. 

No teeth 47 

Cutting incisors 106 

" anterior molars 41 

u canines 40 

" last molars . . ., . . . 20 

Having all the teeth 28 

Total 282 

It is seen that although a large majority of the above cases 
occurred during dental evolution, yet in a certain proportion, 
about one in four, teething could not operate as a cause. My own 
opinion is that dentition is an occasional cause of simple diarrhoea 
though a subordinate one, but evidence is wanting that it is suffi- 
cient of itself to produce inflammation. The diarrhoea of dentition 
is probably non-inflammatory, terminating in inflammation, if such 
a result follow by the co-operation of other and distinct causes. 
This subject is treated of in our remarks relative to dentition. 

An important predisposing cause of intestinal inflammation in 
infants is the rapid development of the intestinal crypts and 
follicles. This development, which increases the liability to or- 



598 INTESTINAL INFLAMMATION OF INFANCY. 

ganic diseases of the intestines, is coincident with dentition. An- 
other important cause remains to be noticed, namely, weaning. 
Weaning is a subject to which less attention is given than its 
importance demands. The summer succeeding the change of diet 
is always in the city a time of great danger to the infant from 
diarrhoeal affections. Mothers uniformly speak with dread of the 
second summer. In this city, nearly every infant taken from the 
breast between the months of April and October very soon be- 
comes affected with diarrhoea, which, if not inflammatory in its 
commencement, soon becomes such. "Weaning in the cool months 
involves less danger, but even then the succeeding summer is one 
of peril. I have memoranda of the time of weaning in forty-six 
infants who were affected with diarrhoea apparently from its dura- 
tion and obstinacy of an inflammatory character. 

Weaned in spring or summer 35 

" " autumn or winter 11 

46 

The reader is referred, for other particulars in reference to wean- 
ing, to the chapter devoted to this subject. 

The above facts and statistics, to which more might be added, 
suffice to show the causative relation of foul atmosphere and inju- 
dicious feeding to the intestinal inflammation of infancy. 

Intestinal inflammation also occurs as a complication of certain 
diseases, especially the eruptive fevers. It is the opinion of some, 
that in measles and scarlatina there is mild inflammation of the 
intestinal mucous membrane, coexisting with the eruption upon 
the skin, and disappearing with it. But in a proportion of cases, 
most frequently in measles, a more intense inflammation arises, 
constituting a serious complication. The peculiar intestinal in- 
flammation in typhoid fever is well known. 

Age. — My observations in reference to the age at which this 
disease occurs were made in the summer months, and, therefore, 
relate to the summer epidemic. The cases embraced in the follow- 
ing table were nearly all observed between the months of May and 
October inclusive: — 

Age. No. of Cases. 

5 months or under 58 

From 5 months to 12 212 

" 12 " "18 174 

" 18 " "24 93 

" 24 " " 36 36 

Total . . . 576 



SYMPTOMS. 599 

This table shows that the infant under the age of six months is 
less liable to entero-colitis than between the ages of six months 
and two years. The small comparative number, however, affected 
under the age of six months, I attribute to the fact that most of 
the infants under this age were wet-nursed. Observations made 
in the institutions of this city in which foundlings are received 
show that the younger the infant is, the more liable it is to be 
affected with this disease, under unfavorable conditions of atmos- 
phere and diet. Thus, in the infant's service of Charity Hospital, 
prior to the adoption of wet-nursing, a large proportion of the 
foundlings received died of well-marked entero-colitis in the first 
and second months, and very few lived till the age of six months. 
A similar fact was observed in the Xew York Infant Asylum in 
Bloomingdale. 1 During my term of service in this institution, I 
preserved notes of forty-nine fatal cases, which I diagnosticated 
entero-colitis, and in many of which post-mortem examinations 
were made. Of these cases, eighteen were one month old or under, 
fifteen from one month to three, eight from three to six, and only 
eight over the age of six months. 

Symptoms. — Intestinal inflammation in the infant usually com- 
mences with moderate diarrhoea. At first there may be no appre- 
ciable anatomical alteration of the mucous membrane except simple 
turgescence of the follicles. The number of evacuations at this 
period frequently does not exceed four to six daily. The color and 
consistence of the dejections vary. The color is sometimes yellow 
at this early stage of the disease, and sometimes green, especially 
in young infants. Whatever the color or appearance of the stools, 
there is great uniformity in one respect, and that is their acidity. 
Litmus paper is reddened by them, and they have a decidedly acid 
odor. Often there is from the commencement more or less fretful- 
ness and febrile reaction. 

In a few days, the disease continuing, the infant, whose stomach 
was at first retentive, begins to vomit. This symptom I found, 
from observations made in 1863 and 1864, in the summer entero- 
colitis of infants, commences in less than a week in the majority 
of cases, though the time varies greatly. In consequence of the 
vomiting and diarrhoea, the patient becomes pallid, the flesh soft 
and flabby, and soon there is evident emaciation. If there is fret- 

1 This institution was discontinued within a year from its establishment, all con- 
nected with it becoming discouraged from the great mortality of the foundlings, 
who were chiefly bottle-fed. 



600 INTESTINAL INFLAMMATION OF INFANCY. 

fulness in the beginning of the sickness, it now ceases, and the 
patient lies quiet, having an exhausted appearance. As the disease 
advances, the features become pinched and wrinkled. The hollow- 
ness of the cheeks and sunken state of the eyes are in striking 
contrast with the appearance presented before the inflammation 
commenced. So feeble is the muscular tonicity in advanced cases, 
that the orbicularis oris and orbicularis palpebrarum lose in great 
part their contractile power, and the mouth and eyes continue open 
during sleep. 

In the beginning of the disease the tongue is moist and covered 
with a light fur. At a more advanced stage it is dry, and in 
dangerous forms of the disease the buccal membrane is red, the 
gums swollen, and sometimes ulcerated, and in young children 
thrush is apt to appear. 

Vomiting, commencing, as I have said, at a later period than 
the diarrhoea, continues, unless relieved by medication or a favor- 
able change of the disease. It is sometimes very intractable. It 
is in most cases associated with an excess of acid in the stomach, 
and is probably mainly due to this, except at an advanced stage of 
the inflammation. The substance vomited has a sour odor, and 
produces a decided reaction with litmus paper. It contains coagu- 
lated casein and undigested particles of whatever food has been 
given. "When the vital powers are much reduced and the inflam- 
mation is violent or protracted, spurious hydrocephalus is present 
or threatening, and the vomiting appears then to be due to the 
cerebral affection. 

The stools sometimes continue, during the whole course of the 
entero-colitis, of nearly the same character as at first. In other 
cases they vary, at different periods, in color as well as consistence. 
They sometimes have a putty-like appearance, from the partly 
digested casein ; at other times they are brown and offensive. A 
very common appearance is that which has been likened to spinach 
or chopped vegetables; occasionally the stools consist largely of 
mucus, with perhaps a little blood — the mucous diarrhoea of 
Barrier. This occurs when colitis is a principal part of the 
disease. The evacuations are seldom so watery as in true cholera 
infantum. 

Occasionally they are yellow when passed, but become green on 
exposure to the air, or from chemical reaction resulting from 
admixture of the urine. 

The microscopic character of the stools in entero-colitis is inter- 
esting. Aside from undigested casein, I have found unaltered 



SYMPTOMS. 601 

fibres of meat, crystalline formations, epithelial cells, single or 
arranged regularly in clusters, as if detached from the villi, 
mucus, sometimes blood, and, in one case, an appearance resem- 
bling three or four crypts of Lieberkuhn united. If the stools are 
green, colored masses of various sizes, but mostly small, are also 
seen with the microscope. The microscopic elements, then, are 
the excrementitious substances, particles of undigested food, in- 
flammatory products, and epithelial cells or fragments of the 
mucous membrane, thrown off by the inflammatory process. 

The "pulse in entero-colitis is accelerated. There is frequently 
increased heat of surface in the commencement, but, as the disease 
continues, the vital powers soon become reduced, and the surface 
is either of the natural temperature or cool. As death approaches, 
the pulse gradually becomes more frequent and feeble, and the 
extremities, sometimes for hours before life is extinct, have a 
cadaverous pallor and coldness. The skin, in intestinal inflam- 
mation, is generally dry, and the urinary secretion diminished. 
In severer forms of the disease, attended by frequent evacuations 
from the bowels, the infant does not pass its urine oftener than 
once or twice daily. The imperfect action of the skin and kidneys 
is a noteworthy feature of the inflammation. The advanced 
stages of entero-colitis are apt to be complicated by two cutaneous 
affections, namely, erythema between the thighs, probably pro- 
duced by the acid and irritating character of the stools, and boils 
upon the forehead and scalp. The latter sometimes extend down 
to the pericranium, and leave permanent depressed cicatrices. 
The external irritation caused by the furuncular affection has 
often seemed to me conservative, as it occurs at the time when 
there is danger of passive congestion of the brain and serous effu- 
sion. When entero-colitis is protracted, and the patient is much 
reduced, remaining constantly in the recumbent position, except 
when held in the arms of the mother or nurse, another symptom 
frequently arises, namely, a dry cough, which continues till the close 
of life, if the case be fatal, and subsides slowly if the disease termi- 
nate favorably. The complication which gives rise to this symptom 
will be considered hereafter. As death approaches, the infant 
sometimes becomes more fretful; it turns peevishly from play- 
things, rolls its head, or the head has an unsteady movement; and 
sometimes the stomach is more irritable. The experienced physi- 
cian rightly interprets these symptoms as the forerunner of cerebral 
accidents. In other cases there is too great prostration even for 
the exhibition of restlessness, and the infant lies quiet. As death 



602 INTESTINAL INFLAMMATION OF INFANCY. 

approaches, the infant becomes drowsy. The limbs are cool. It 
refuses to nurse, or, if spoon-fed, takes nutriment apparently with- 
out relish. The pupils are contracted, and insensible to light. 
The eyes are bleared, and a puriform secretion occasionally collects 
between the lids. The stools are less frequent, and the vomiting, 
if previously present, ceases. Death occurs quietly. 

Sometimes, however, convulsive movements precede death, gene- 
rally slight, as of one arm, or of the limbs or one side. Uraemia 
may be the immediate cause of death in certain cases. 

In chronic entero-colitis there is extreme emaciation for a con- 
siderable time before death. The skin of the extremities lies in 
wrinkles; the joints, from contrast, appear enlarged, and the fingers 
and toes elongated ; the angular projections of the bones are pro- 
minent. The hollowness of the cheeks and eyes causes the infant 
to appear much older than it really is. Death occurs in a state of 
extreme exhaustion. 

The above description applies to infantile entero-colitis, as it so 
frequently occurs in the cities. It is sometimes much more violent, 
attended by much greater febrile reaction, and is more speedily 
fatal. Especially is this the case when it is due to the impression 
of cold: such cases are not infrequent in the winter months, in the 
country as well as city. 

Instead of the mild and gradual commencement which I have 
described, infantile entero-colitis may be preceded by violent 
symptoms — a true cholera morbus. Yomiting and purging, more 
or less severe, precede the inflammation. Among my records are 
cases which commenced in the summer season from eating goose- 
berries, currants, cherries, and cheese : the cholera morbus pro- 
duced by these indigestible substances ending in protracted inflam- 
mation. 

Cholera infantum, in which the symptoms from the first are 
violent and alarming — a disease attended by vomiting and frequent 
watery stools, occasionally ends in the establishment of intestinal 
inflammation ; and, as there are no symptoms by which it is possible 
to determine precisely when the inflammation begins, it seems as 
if the inflammation itself had this violent commencement. But 
the severe choleraic symptoms usually abate before the inflamma- 
tion is established. 

Anatomical Characters. — Billard says: "In eighty cases of 
inflammation of the intestines that I examined with great care, 
there were thirty of entero-colitis, thirty-six of enteritis, and 
fourteen of colitis." M. Legendre, in twenty-eight cases of diar- 



ANATOMICAL CHAEACTEES. 603 

rhoea, found colitis alone in nine, and in the cases in which ente- 
ritis occurred colitis was also present. Rilliet and Barthez state, 
that in certain rare instances almost the entire digestive tube is 
affected ; that in exceptional cases the principal lesion is found in 
the small intestines, while, on the other hand, the large intestine 
is the part of the alimentary canal which is most frequently and 
intensely inflamed. Billard describes four kinds of intestinal 
phlegmasia : First, erythematic ; second, with altered secretion ; 
third, follicular ; fourth, with disorganization of tissue. In some 
of the best works on diseases of children, published subsequently 
to that of Billard, different forms of inflammation are described, 
according to the presence or absence of certain anatomical changes, 
as ulceration or softening. Practically little is gained by such a 
division of the general disease, and the lesions which are made 
the basis of the division are often merely the result of severe and 
protracted, simple or erythematic, inflammation. I have records 
of the post-mortem appearances in eighty-two cases of intestinal 
inflammation in the infant. Eleven of these occurred in private 
or dispensary practice; about fifty in the Nursery and Child's 
Hospital, and the remainder in the Infant Asylum. Since pre- 
serving these records, I have witnessed a larger number of post- 
mortem examinations of infants who died of this disease in these 
institutions, and the lesions corresponded in general with those 
already observed. The question may properly be asked, can in- 
flammatory hyperemia of the intestinal mucous membrane be 
distinguished from simple congestion if there is no ulceration and 
no appreciable thickening of the intestine? This is sometimes 
difficult, and it is possible that occasionally I have recorded as in- 
flammatory what was simply a congestive lesion, but I do not 
think that I have incorporated a sufficient number of such cases 
to vitiate the statistics. In a large proportion of the autopsies 
there was manifest thickening of the intestinal mucous membrane 
or other unequivocal evidence of inflammation. The following is 
an analysis of the eighty-two cases : — 

The upper part of the small intestine, embracing the duodenum 
and jejunum, was found inflamed in twelve cases. It was free 
from inflammation, and of a pale color, in fifty-one cases. The 
ileum was inflamed in forty-nine cases, and the ccecal portion, in- 
cluding the ileo-ccecal valve, was the part in which the inflamma- 
tion was uniformly most intense and to which it was often confined. 
In sixteen cases there was no ileitis, and in thirteen no enteritis 
whatever. Therefore, the ileum was inflamed in all but three of 



604: INTESTINAL INFLAMMATION OF INFANCY. 

the cases of enteritis, in which the records give the exact location 
of the disease. In fourteen cases there was vascularity in streaks 
or in patches, or simple arborescence in some part of the small 
intestines, the records not stating its exact location. 

In most cases the inflamed mucous membrane was perceptibly 
thickened. Occasionally, especially if the vascularity was slight, 
the thickening was scarcely appreciable. In one case there was 
so much thickening of the ileum next to the ileo-ccecal valve that 
the mucous coat appeared as if closely studded with small warts. 
Ulcers of small size were found in the mucous membrane of the 
small intestines in lave cases. These ulcers in one case were in the 
jejunum, in two in the ileum, and in two in both these divisions 
of the intestine. They were for the most part quite superficial, 
and circular or oval. 

It is seen from the above records that the portion of the small 
intestine most frequently inflamed was the ileum. The inflamma- 
tion usually affected the ileo-ccecal valve, and extended from it to 
a greater or less extent along the small intestine. In general, 
when inflammatory patches were found in different parts of the 
small intestine, those in the ileum nearest the ileo-ccecal valve 
presented the greatest vascularity and thickening. Billard noticed 
in his cases the frequency and intensity of the inflammation in 
the terminal portion of the ileum, and the consequent thickening 
of the ileo-ccecal valve, and conjectured that the vomiting so com- 
mon and obstinate in enteritis might be due to obstruction at the 
ileo-ccecal orifice in consequence of this thickening. I have often 
seen the orifice reduced to a very small size from the hyperemia 
and thickening of the valve, but have not seen any accumulation 
above it or other evidence of obstruction. 

The inflamed mucous membrane was softened in greater or less 
degree according to the intensity of the inflammation. Sometimes 
the vessels of the submucous connective tissue were injected, and 
this tissue infiltrated. The softening of the mucous coat, and the 
firmness of its attachment to the parts underneath, varied consider- 
ably in different specimens. I was able, in cases in which there 
was considerable softening, to detach readily the mucous coat with 
the nail or back of the scalpel, within so short a period after death 
that it was evident that the change of consistence could not have 
been cadaveric. 

The infants in whom the duodenum and jejunum presented the 
inflammatory lesions were, with few exceptions, under the age of 



ANATOMICAL CHARACTERS. 605 

three months, and in many of these cases there was hyperemia of 
the gastric mucous membrane, and in some also stomatitis. 

In all the cases except one, namely, in eighty-one, there were 
lesions indicating inflammation of the mucous membrane of the 
colon* In thirty-nine, the inflammation had affected nearly or 
quite the entire extent of this portion of the intestine ; in fourteen, 
it was confined to the descending portion entirely, or almost 
entirely ; in twenty-eight cases, the records state that colitis was 
present, but its exact location was not mentioned. In eighteen of 
the examinations, the mucous membrane of the colon was found 
ulcerated. According to these statistics, there is colitis in nearly 
every case of intestinal inflammation in infancy, and in a large 
proportion of cases also ileitis. The portion of the colon which 
is most frequently inflamed is that in and immediately above the 
sigmoid flexure. If the colitis affects other portions also, it is 
nevertheless in this part that we find the most marked inflamma- 
tory lesions. 

The solitary glands, both of the large and small intestines and 
Peyer's patches, are involved in nearly all cases of this disease. 
Even in non-inflammatory diarrhoea they become tumefied, so as 
to be distinctly visible and somewhat elevated. In entero-colitis, 
as we have already seen, they present different appearances, ac- 
cording to the degree and duration of the inflammation. In 
recent cases, and in parts of the intestine where the inflammatory 
action has been mild, there is often no perceptible change of these 
glands except slight enlargement with vascularity. This enlarge- 
ment is most apparent if the intestine is viewed by transmitted 
light, when not only the glands are seen to be swollen, but their 
central dark points are also quite distinct. If there is a higher 
grade of inflammation, or inflammation more protracted, the volume 
of the solitary follicles is so increased that they rise above the 
common level and present a papillary appearance. Peyer's patches 
are in a corresponding degree thickened. 

The enlargement of these glands is due to hyperplasia, namely, 
an augmentation in the number of the elementary cells. The 
ulceration in the cases which I have examined appeared to be 
primarily and chiefly follicular. "While some of the solitary 
glands in a specimen were found simply tumefied, others were 
slightly ulcerated, and others still nearly or quite destroyed. The 
ulcers were usually from one to three lines in diameter, circular 
or oval, with edges a little raised, and red. They resembled in 
appearance the ulcers in follicular stomatitis. In one or two 



606 INTESTINAL INFLAMMATION OF INFANCY. 

instances I have seen small coagula of blood in the ulcers, and I 
have also seen ulcers which had evidently been larger, having 
partially healed. The principal seat of the ulcers was in the 
descending colon. They were either found in this portion of the 
intestine only, or, if occurring elsewhere, they were here most 
abundant. 

Those in whom I have found ulcers have been ordinarily over 
the age of six months, which is the time when there is greatest 
development and activity of the glandular apparatus. In none of 
the cases observed by me were Peyer's patches ulcerated, though 
generally tumefied. 

In cases in which the caput coli was inflamed, I have sometimes 
found the mucous membrane of the appendix vermiformis also 
injected and thickened. In one case only was there pseudo- 
membrane upon the inflamed surface. This was in the descending 
colon, and it was thin like a film. The rectum presented no in- 
flammatory or other lesions, or but slight lesions in comparison 
with those in the colon. Often, when there was almost general 
colitis, the rectum was found of a pale color, or but slightly 
vascular. This may explain the rare occurrence of tenesmus in 
infantile entero-colitis. The amount of mucus secreted from the 
intestinal surface in this disease is considerably in excess of the 
normal quantity. It often forms a layer upon the mucous mem- 
brane of the intestines, and appears in the stools, mixed with 
epithelial cells and sometimes with blood or pus. If the quantity 
of mucus appearing in the stools is considerable, the disease has 
sometimes been designated mucous diarrhoea, or mucous disease ; 
but there does not seem to me sufficient reason, either anatomical 
or clinical, for considering it a distinct affection. 

The mesenteric glands are ordinarily enlarged, unless in very 
young infants. They are frequently found as large as a large pea, 
or even larger, and of a light color, from the ansemic state of the 
infant. In exceptional instances certain of them are found to have 
undergone cheesy degeneration. The enlargement of these glands, 
like that of the solitary follicles and Peyer's patches, is from 
hyperplasia. The condition of the stomach was recorded in sixty- 
nine cases. In forty-two it was healthy ; in seventeen red, ap- 
parently inflamed; in seven of a pink color; and in three there 
were ulcerations, probably cadaveric. The usual healthy condition 
of the stomach is a noteworthy fact, taken in connection with the 
frequent vomiting, in entero-colitis. I have stated elsewhere that 
stomatitis is also a common complication in protracted and grave 



ANATOMICAL CHARACTERS. 



607 



cases, accompanied by sponginess of the gums, which bleed if 
pressed or rubbed. The buccal surface in these cases is more vas- 
cular than natural, and, if the vital powers are much reduced, 
superficial ulceration is not infrequent, especially of the gums. In 
infants under the age of three or four months, oesophagitis is also 
a common accompaniment of entero-colitis. 

Thrush, though a frequent complication under the age of. three 
or four months, is rare in older infants. Thrush, in infants over 
the age of eight or ten months, occurring in connection with in- 
testinal inflammation, is an unfavorable prognostic sign, indicating 
a gravity of the intestinal disease, which commonly eventuates in 
death. 

There exists an opinion in the profession that the liver is in 
fault in this disease, especially in that form of it which I have 
described as a summer epidemic of the cities. This opinion is, 
probably, less prevalent than formerly, but it is still held by many, 
and it influences, more or less, the choice of therapeutic agents. 
In the appendix (E) is a table, which presents the condition of 
the liver in thirty-two cases of this disease. These cases occurred 
during the summer epidemic. 

There was no evidence, from the post-mortem appearance of the 
liver in these cases, of any congestion, or torpidity, or hyper- 
activity, or perverted secretion. The size of the liver was in 
some cases very different in those of about the same age, but 
probably there was no greater difference than usually obtains 
among glandular organs within the limits of health. The fol- 
lowing table gives the weight of the liver in twenty cases in 
which the weight of this organ and the age of the patient are 
recorded: — 



Age. 




Age. 




4 weeks 


5 ounces. 10 months . 


, 6f 


2 months 


. 3^ ' 


13 " 


6 


2 " 


H ' 


14 " 


9 


4 " '. 


5 ' 


15 " 


6 


5 " . 


H ' 


' 15 " 


•71 
'2 


5 " 


9 ' 


15 " 


u 


7 " 


H ' 


16 " 


6 


7 " . 


6 ' 


19 " 


4§ 


7 " 


H ' 


' 20 " 


H 


9 " 


8 ' 


' 23 " 


15 



6| ounces. 



I do not have access to tables giving the weight of the healthy 
liver at different ages, but in none of the above cases did the size 
or the weight seem to me to be above the healthy standard, except 



INTESTINAL INFLAMMATION OF INFANCY. 

in one, in which this organ was quite fatty. But in this case the 
degeneration and enlargement of the liver were doubtless due to 
the tubercular disease. 

In most of the cases the liver was examined microscopically, 
and the only fact worthy of note observed was the variable 
amount of fatty matter. Sometimes it was in excess, sometimes 
in moderate quantity or rather deficient, and sometimes in greater 
amount in one portion of the organ than in another. 

The prevalent belief, then, that the liver is greatly affected in 
the summer epidemic of entero-colitis, receives no corroboration 
from the inspection of this organ. The only pathological state (if 
it be such) observed in it relates to the amount of oily matter, and 
this obviously requires no special treatment. 

The cutaneous affections complicating entero-colitis have already 
been alluded to. 

Frequently, at post-mortem examinations of infants who have 
died of entero-colitis, intussusceptions are found in the small 
intestines. These probably in general occur at the moment of, or 
not long before, death, but I have in a few instances found intus- 
susceptions which sustained the weight of two feet or more of 
intestine without being reduced, and which, from being in their 
interior more vascular than the contiguous membrane either above 
or below, probably occurred some hours, possibly days, before death, 
but, being sufficiently pervious to allow the food to pass, symptoms 
of obstruction were absent. 

It has been said, in speaking of the symptoms, that a cough is 
common in the advanced stages of entero-colitis, particularly when 
the disease is protracted for weeks or months. From the great 
emaciation and the character of the cough, the physician as well 
as friends is very apt to suspect the presence of tubercles. In the 
eighty-two examinations, however, which I have made of entero- 
colitis of the summer season, in many of which emaciation was 
extreme, there were tubercles in only one case. The cough was 
found to be due to solidification of the posterior and dependent 
portion of one or both lungs. The exact pathological character of 
this solidification of lung (hypostatic pneumonitis) is treated of in 
our remarks on diseases of the respiratory organs. 

In the cases of entero-colitis which were complicated with this 
state of the lungs, I have not usually found enough of the lung 
tissue involved to make any perceptible difference in the sound 
on percussion. Its extent of solidification was sometimes not 
more than two or three lines, and frequently not more than a 



DIAGNOSIS — PROGNOSIS. 609 

quarter to half an inch in an antero-posterior direction, although 
it embraced nearly or quite the entire posterior surface of the lung. 

The state of the brain in the entero-colitis of infancy is inter- 
esting to the pathologist. When the disease is protracted, this 
organ wastes like the body and limbs. In the young infant, in 
whom the cranial bones are still ununited, the occipital and some- 
times the frontal become depressed in proportion to the loss of 
brain substance, so that the cranium is quite uneven. In older 
children with the cranial bones consolidated, serous effusion occurs 
according to the degree of waste, thus preserving the size of the 
encephalon. The effusion is chiefly external to the brain, extend- 
ing on each side over the convolutions from the base to the vertex. 
The quantity of serum varies from one or two drachms to an 
ounce, or even more. The serous effusion is associated with 
passive congestion of the cerebral vessels and cranial sinuses. 

Diagnosis. — The only disease with which infantile inflammation 
of the intestines is likely to be confounded is non-inflammatory 
diarrhoea. The means of diagnosticating the one from the other 
are indeed uncertain. There is no pathognomonic sign or symp- 
tom, in the majority of cases, in either affection. Occasionally we 
are able to diagnosticate colitis from the presence in the stools of 
mucus or mucus tinged with blood. Abdominal tenderness, which 
in the adult is so important a diagnostic symptom of intestinal 
inflammation, is generally absent in the infant, or, if present, is 
not easily ascertained. The presence of fever and the severity 
and persistence of the symptoms, render it probable that the disease 
is inflammatory. 

In general I have found that, if diarrhoea continued more than 
a week in the summer season, it had become inflammatory. Some- 
times, however, as I have in at least three cases seen, and as the 
French physicians state, diarrhoea may continue for a much longer 
time, attended by extreme emaciation and terminating fatally, 
and yet at the post-mortem examination no lesion of the intestines 
be found, except a tumefied state of the intestinal glands. Practi- 
cally it matters little whether we ascertain the inflammatory or 
non-inflammatory character of the disease, as we determine the 
proper mode of treatment from the symptoms and general condi- 
tion of the patient. 

Prognosis. — I have said that intestinal inflammation is one of 

the most fatal of infantile diseases. Still it is possible, by proper 

hygienic measures and a judicious selection and use of medicines, 

to save a large proportion of those affected. Entero-colitis and 

39 



610 INTESTINAL INFLAMMATION OF INFANCY. 

most of its complications are of such a nature that we may have 
reasonable hope that the infant will recover if all measures cal- 
culated to control the disease are employed. Many do recover from 
a state of emaciation and feebleness which, occurring in any other 
pathological state, would be almost necessarily fatal. The most 
unfavorable symptoms in this disease, except those due to extreme 
prostration or collapse, arise from the state of the brain. Boiling 
the head, squinting, feeble action of the pupils, spasmodic or ir- 
regular movements of the limbs, indicate the near approach of 
death. There are many facts which should be taken into con- 
sideration in making a prognosis. The age of the infant, the 
time in the year, the surroundings, especially in reference to the 
impurity of the atmosphere, are to be considered, as well as the 
present state of the patient. 

Intestinal inflammation of infancy might, in many instances, be 
prevented by judicious measures. Especially is it preventable in 
those cases in which the exciting cause is dietetic. The reader is 
referred to the chapters on weaning and artificial feeding, for facts 
in reference to this matter. Unfortunately, however, the physician 
is not generally consulted in regard to the alimentation of the 
infant, or the time and manner of weaning, or other important 
matters of regimen, until diarrhoea, inflammatory or non-inflam- 
matory, is established ; his purpose is then not to prevent, but to 
cure. 

Treatment. Regimenal Measures. — Intestinal inflammation of 
infancy requires somewhat different treatment, according to the 
cause, as well as the condition of the patient. If it occur in an 
infant of previous good health, and from exposure to cold, its diet 
should at first be reduced. If it be nursing, it should take the 
breast less frequently. It will then receive less nutriment, not 
only in consequence of the longer interval between the times of 
nursing, but because the milk remaining in the breast becomes 
more watery and less nutritious. If thirsty, it may take a little 
light barley-water or gum-water. If the infant be weaned, a 
corresponding reduction in its nutriment should be made. 

These cases require mild counter-irritation over the abdomen, 
followed by emollient poultices, or warm water applications covered 
with oil silk. After the acute stage has passed, more frequent 
nursing and more nutritious diet should be allowed. Often the 
alcoholic stimulants in barley-water, and sometimes the animal 
broths, are required in this stage of the disease. Exhaustion should 
be guarded against in the infant. 



TREATMENT. 611 

As one of the chief causes of intestinal inflammation of infancy, 
particularly in the city, is the use of food which does not agree 
with the digestive system, feeble and easily deranged at that early 
age, attention should be directed, in those cases in which the dis- 
ease does not seem to be due to the impression of cold, not only 
to the nature of the food, but to the mode of its preparation and 
the quantity given. To the young infant with entero-colitis, no 
food is so easily digested, and is therefore so suitable, as human 
milk. The bottle-fed infant, under the age of twelve months, 
remaining in the city in the summer season, and affected with 
intestinal inflammation, cannot in general be successfully treated 
unless it is provided with a wet-nurse. Frequently, when the 
diarrhoea continues in spite of all other measures hygienic and 
medicinal, the infant begins at once to improve by the employment 
of a wet-nurse. It is sometimes really surprising to observe as a 
consequence of this measure the rapid and complete restoration to 
health from a state of extreme emaciation. 

In certain cases the breast-milk, either of the mother or wet- 
nurse, disagrees with the infant, and its use aggravates the intes- 
tinal disease. In the country, or in the city in the cool months, 
weaning may be proper under such circumstances. Certainly 
weaning or the employment of another wet-nurse is required. In 
the city in the summer months, for reasons elsewhere fully stated, 
weaning is a very injudicious if not fatal measure, and, if the 
entero-colitis is aggravated by the character of the mother's milk, 
a wet-nurse should be engaged. If the breast-milk is suspected 
as the cause or one cause of the infant's sickness, it should be 
examined by the microscope, before a change in diet or in nursing 
is recommended. It has been ascertained by the microscope, that 
the elements of colostrum which have a purgative effect may return 
at any period of lactation. 

If the mother's milk disagrees, and a wet-nurse for any reason is 
not employed, it is then necessary to recommend a diet which will 
be the best possible substitute for the natural aliment. Well- 
boiled barley-water, or Ridge's food, the basis of which is wheat- 
flour, the upper third of cow's milk when it has stood two or three 
hours, the expressed juice of lean beefsteak slightly roasted, and 
scraped raw beef, may be mentioned among the articles of diet 
which I have found useful in these cases. For facts in reference 
to artificial feeding, and for dietary formulae, the reader is referred 
to chapters relating to the diet of infancy. 

Attention to the diet of infants affected with intestinal inflam- 



612 INTESTINAL INFLAMMATION OF INFANCY. 

mation is obviously of the utmost importance, but one chief cause 
of the disease, especially of the great summer epidemic of the 
cities, we have seen to be atmospheric. This requires attention 
on the part of- the practitioner to a different matter in the hygi- 
enic management of these cases, namely, the state of the air which 
the infant breathes. In the cool months, the atmosphere is more 
pure than in the summer months, as it contains less of those 
noxious gases which arise from decaying animal and vegetable 
substances. In those months, then, in which the weather is such 
that there is no decomposition of organic matter, the atmospheric 
cause of entero-colitis is not operative, and little is gained for the 
patient by change of locality. But in the summer season one of 
the most important conditions of successful treatment of this and 
the other diarrhoea! maladies of infancy is the removal of patients 
from an impure to a pure atmosphere. Physicians of experience 
all agree in the choice of elevated localities, containing a sparse 
population, and remote from the sea-shore. Many are the in- 
stances every summer in this city of -infants removed to the 
country with intestinal inflammation, with features haggard and 
shrunken, with limbs shrivelled and skin lying in folds, too weak 
to raise or at least hold their heads from the pillow, vomiting 
nearly all the nutriment taken, with stools frequent and thin, re- 
sulting in great measure from molecular disintegration of the 
tissues, presenting indeed an appearance seldom seen in any other 
disease except in the last stages of phthisis, and returning in late 
autumn, with the cheerfulness, vigor, and rotundity of health. The 
localities usually preferred by the physicians of this city are the 
elevated portions of New Jersey and Eastern Pennsylvania, the 
Highlands of the Hudson, the central and the northern parts of 
New York State, and Northern New England. Taken to a salu- 
brious locality, the infant will soon begin to improve after it has 
recovered from the fatigue of travelling, unless the case is incu- 
rable. 

Sometimes parents, not noticing the immediate improvement 
which they had been led to expect, return to the city without 
giving the country fair trial, and the life of the infant is almost 
necessarily sacrificed. Returned to the foul air of the city while 
the weather is still warm, it sinks rapidly from an aggravation 
of the malady. Dr. James Jackson recommends, if the infant do 
not improve where it is taken, that it should be conveyed to 
another locality. This is good advice, provided the selection be 
made of a place elevated, remote from the sea-shore, and having a 



TKEATMENT. 613 

sparse population. The infant, although it has recovered, should 
not be brought back while the weather is still warm. One attack 
of the disease does not diminish but increases the liability to a 
second seizure. 

If the situation of the family is such that it is not practicable 
to take the infant to the country, and such cases are frequent 
among the poor, it should be kept much of the time in the open 
air; it is a common practice in this city to take such patients in 
the daytime to the sea-shore, or upon ferry boats. Dr. E. H. Parker 
says: "Many of my patients are sent to the ferries to cross them, 
so that the cool fresh sea breeze may fan them, and it acts some- 
times like magic, to raise their drooping heads." I have not 
observed such marked benefit in these cases from the sea breeze as 
from the air of elevated localities, which can generally be found in 
the vicinity of cities, and are easily accessible. 1 

Medicinal Treatment — Sometimes it is proper to commence treat- 
ment by the employment of a gentle purgative, particularly when 
the disease commences abruptly from a state of previous good 
health. It is then frequently caused by exposure to cold, or more 
rarely by some indigestible and highly irritating substance in the 
intestines. In such patients, there is often a full habit. The 
pulse is strong and quick, the heat of surface great, the face 
perhaps flushed, the stools sometimes slimy and bloody, sometimes 
green or brown. It is proper and often serviceable, when there is 
this commencement of the affection, to give a single dose of castor 
oil or syrup of rhubarb. Any indigestible substance, if present, is 
removed from the intestine, and opiates or other remedies designed 
to control the disease may then be more successfully employed. 
Such cases occur in the winter not less than in the summer, and 
in all localities, rural as well as in the city. But the summer 
epidemics of intestinal inflammation in the cities do not in general 
require such preliminary treatment. Diarrhoea, moderate, perhaps, 
has already continued for a time when the physician is called, and 
no irritating substance remains except the acid, which is abundantly 
generated in the intestine in this disease, and which we have a 
means of removing without purgation. Preliminary treatment 
having been employed or not, according to the nature of the attack 



1 The remarks made in reference to the use of pepsin in indigestion and non- 
inflammatory diarrhoea apply also to those cases of inflammatory diarrhoea which 
are due to feebleness of the digestive function. 



614 INTESTINAL INFLAMMATION OF INFANCY. 

and condition of the patient, remedies calculated to arrest the 
inflammation should then be prescribed. 

The medicines which should be employed are chiefly of three 
kinds, namely, alkalies, opiates, and astringents; sometimes one 
or two kinds only, and sometimes all three, according to the cha- 
racter of the evacuations. The antacid treatment is, of course, 
required in those numerous cases in which the stools are acid, and 
there is no better alkaline remedy for the diarrhoea in this disease 
than the preparations of chalk. The creta prgeparata of the phar- 
macopoeias, in doses of two or three grains to a child one year old, 
or the mistura cretse in teaspoonful doses, are eligible preparations, 
and are commonly employed. These medicines should be repeated 
in two hours, or a longer time, according to the state of the patient- 
Chalk given for a moderate period is innocuous, and may be ad- 
ministered to the youngest child. 

In Europe the crab's eye is much used, and it is stated that it 
is sometimes effectual in controlling the disease, when the chalk 
fails. The following is a formula recommended by Bouchut : — 

R.. Ocul. cancror. pulv. gr. x ; 
Aq. fceniculi, 
Syr. rhei, aa^ss. M. 

One teaspoonful every hour. In this country the same antacid 
has been also employed, though less frequently than the prepara- 
tions of chalk. J. F. Meigs, of Philadelphia, prescribes it as fol- 
lows : — 

R. Ocul. cancror. pulv. &j ; 
Acacias pulv. 5ij ; 
Sacch. alb. 9j ; 
Aq. fontis, 
Aq. cinnaniom., aa^jss. M. 

A teaspoonful four, five, or six times daily. By means of this 
alkali alone, aided by proper hygienic measures, the disease is 
sometimes arrested, but, unless circumstances are favorable and 
the case is mild, other medicines are required. 

Opium is used by most practitioners in the treatment of intes- 
tinal inflammations of infancy. Either as a main remedy or ad- 
juvant it is employed, and properly, in nearly all severe cases. For 
a young infant paregoric is an eligible preparation of opium. For 
the age of one month, the dose is three to five drops ; for the age 
of six months, ten to twelve drops, repeated in three hours or a 
longer time, according to the state of the patient. After the age 
of six months, the stronger preparations of opium are more fre- 



TREATMENT. 615 

quently used. At the age of one year, the liq. opii compositus or 
tincture opii may be given in doses of one to two drops. Dover's 
powder is also an excellent medicine in this disease, given in doses 
of three-fourths of a grain to an infant one year old. 

Opium is, however, in general best given in mixtures which will 
be mentioned hereafter. It quiets the action of the bowels, and 
diminishes the number of evacuations. It is contra-indicated or 
should be used with caution if cerebral symptoms are present. 
Sometimes in the commencement of the disease, if there is much 
febrile reaction, the patient may be drowsy and in danger of con- 
vulsions. Then opiates should be given cautiously or withheld. 
Also in the advanced stages of this disease, when, perhaps, there 
is more or less serous effusion in the cranial cavity, opium should 
be cautiously used, as it might tend to produce that fatal stupor, 
in which the unfavorable cases are apt to terminate. 

Astringents are required when the evacuations are thin and fre- 
quent, and are not sufficiently controlled by the remedies already 
mentioned. Those of a vegetable nature are usually preferred, as 
they are compatible with chalk, and may be given in combination 
with it. The astringents commonly used are, catechu, kino, kra- 
meria, tannic and gallic acids. Logwood and blackberry roots are 
also occasionally employed. 

If the disease become chronic, nitrate of silver and acetate of 
lead are sometimes useful. Astringents should not be given if the 
stools are scanty and consistent though frequent, nor should they 
be employed if the evacuations are muco-sanguinolent, as in the 
dysentery of the adult. 

I will now mention the various combinations of medicines which 
have been found the most useful in intestinal inflammation. 

In all those cases in which the evacuations consist chiefly of 
mucus, or mucus and blood, and in all recent cases in which the 
evacuations are scanty, and there is considerable fever, one of the 
best formulae is the following, which is similar to that recom- 
mended by Dr. West: — 

R. Tinct. opii gtt. xij ; 
Pulv. gum acac, 
Pulv. saccli. alb., aa £j ; 
01. ricini 5j to 3ij ; 
Aq. cinnamom. ^jss. M. 

One teaspoonful every three hours. In these cases, also, Dover's 
powder, given at the same interval with half a teaspoonful of 



616 INTESTINAL INFLAMMATION OF INFANCY. 

castor oil once or twice daily, will have good effect in controlling 
the disease. 

In the more common forms of infantile entero-colitis, in which 
the stools are green, or brown, or yellow, and are watery and fre- 
quent, one of the best medicines is the pulv. cret. comp. c. opio, 
combining, as it does, alkali, opiate, and astringent. 

Three grains may be given every two or three hours to a child 
one year old, till the diarrhoea is controlled. For young infants 
paregoric, catechu, and chalk, as recommended in the treatment of 
non-inflammatory diarrhoea, is a useful mixture. Laudanum or 
liq. opii compos, in proper quantity may be substituted in place of 
the paregoric, and kino or krameria in place of the catechu. 

Gallic or tannic acid is sometimes administered with Dover's 
powder, or with the compound powder of chalk and opium, but 
given in this way it is nauseating and apt to be vomited. If the 
evacuations are not frequent or watery, the opiate and chalk 
mixture may be prescribed without the astringent with a good 
effect. 

I do not know that any benefit is gained in intestinal inflam- 
mation of the infant by the use of mercurials, and in many cases 
certainly much harm would result. They are not now commonly 
prescribed in the enteritis or colitis of adults, and there is no 
lesion in infantile entero-colitis, either as regards the liver or 
intestines, which requires their administration. In the choleriform 
diarrhoea, which sometimes precedes intestinal inflammation, the 
use for a day or two of small doses of calomel or hydrarg. cum cret. 
is thought by some judicious practitioners to be of service, but, 
when it has appeared to be beneficial in intestinal inflammation, 
the good effect is probably due chiefly to the opium which is 
administered with the mercurial. 

Often the disease continues, notwithstanding the use of the 
above remedies, or if temporarily relieved, the causes still opera- 
ting, it returns. In these protracted cases, attended perhaps with 
more or less ulceration of the mucous membrane, the mineral 
astringents may be prescribed. Acetate of lead may be given in 
doses of one-fourth of a grain to an infant one year old. Nitrate 
of silver is, however, more frequently prescribed in Europe, espe- 
cially on the continent. It may be given in doses of one-twentieth 
to one-twelfth of a grain in a little mucilage or simple syrup. 

Enemata. — These are of great service in many cases of intestinal 
inflammation. At any stage of the disease, when the stomach is 
irritable and medicines are not retained, they may be advanta- 



TREATMENT. 617 

geously employed. Laudanum especially is often given in this 
way to the infant with great benefit. It may be prescribed mixed 
with a little starch water, and the best instrument for administer- 
ing it is a small glass or gutta-percha syringe, the nurse retaining 
the enema for a time by means of a compress. Beck, in his Infant 
Therapeutics, advises to give by injection twice as much of the 
opiate as would be administered by the mouth. A somewhat 
larger proportion may, however, be safely employed. Astringents 
may also be given by enema. Bouchut, speaking of these thera- 
peutic agents, says : "All these substances may be given as enemata, 
composed of three to six ounces of the vehicle holding in solution 
seven to ten grains of the extract of rhatany or monesia. If tannin 
is used, it should be in the dose of four to seven grains. In the 
same way and for the same end, fifteen to thirty grains of alum, or, 
better still, less than one grain of the nitrate of silver. These last 
enemata are daily employed at the decker Hospital. If their use 
is not constantly followed by success, there always results, at least, 
a decided amelioration quite capable of dissipating the objections 
raised against their employment." 

Since the inflammation is ordinarily most intense in the descend- 
ing colon, and is sometimes confined to this portion of the digestive 
tube, benefit results in certain obstinate cases from the injection 
into the rectum of a solution of nitrate of silver in warm distilled 
water in the proportion of one grain to six or eight ounces. A 
little laudanum ma} 7 be added. This treatment has been employed 
in the Nursery and Child's Hospital, but only as an adjuvant to 
remedies administered by the mouth. 

In most of those cases of intestinal inflammation which occur 
under the depressing effect of warm weather, alcoholic stimulants 
are required almost from the commencement of the disease, and 
their use is beneficial in chronic or protracted cases, whatever the 
cause or season. Bourbon whiskey or brandy is the best of these 
stimulants, and it should be given in small doses, repeated at 
intervals of two hours. I have usually ordered three or four drops 
to an infant one month old, and an additional drop or two drops 
for each month. The stimulant is not only useful in sustaining 
the vital powers, but it also aids in relieving the irritability of 
stomach. 

The diarrhoea is, in general, more easily controlled than the 
vomiting. A remedy which with me has been useful in relieving 
the latter symptom is the neutral mixture : — 



618 INTESTINAL INFLAMMATION OF INFANCY. 

I£. Potas. bicarbonate gr. xxv; 
Acid, citric, gr. xvij ; 
Aq. amygdal. amarae ^j ; 
Aquae t fij. Misce. 

Dose, one teaspoonful to a child from eight to twelve months 
old, repeated according to the nausea or vomiting. The following 
prescription to relieve this symptom, which is similar to one em- 
ployed in the Nursery and Child's Hospital of this city, has the 
desired effect in a certain proportion of cases: — 

I£. Acid carbolic, gtt. ij ; 
Aq. calcis ^ij. Misce. 

Dose, one teaspoonful with a teaspoonful of milk, breast-milk if 
the infant nurses, repeated according to the symptoms. Lime- 
water alone sometimes diminishes the vomiting when there is 
great acidity, but it is rendered more effectual by the addition of 
carbolic acid. Yomiting is frequent in the summer epidemics of 
intestinal inflammation in the cities, and it is in this form of the 
disease, induced by an impure atmosphere and an unsuitable diet, 
that I have observed the greatest benefit from the above prescrip- 
tions. When the inflammation occurs in other seasons, and is 
produced by other causes, vomiting is less frequent, and is more 
easily controlled. It may then require no special treatment. 

While I approve the above mode of treatment, which is re- 
printed from the first edition, more recent experience, and es- 
pecially observations made in the large class of children's diseases 
in the Out-door Department at Bellevue, convince me that the 
subnitrate of bismuth is a valuable remedy not only for this 
disease, but also for cholera infantum, and one which is appropriate 
in most cases. It has, indeed, long been used in the diarrhceal 
affections of infancy, but in doses much too small. Its effect is be- 
lieved to be entirely local, namely upon the gastro-intestinal surface 
and its secretions. It undergoes or effects some chemical change, 
for the stools after its use become dark, and at the same time more 
consistent. While it diminishes the frequency of the evacuations, 
it is at the same time one of the most efficient antiemetics. The 
following formula is for an infant one year old : — 

R. Bismuth, subnit. 5j ; 

Pulv. cret. comp. c. opii 5 s s. Misce. 
Divid. in chart. No. x. One powder every three hours. 

I believe that this is the best remedy that can be prescribed for 
the epidemic entero-colitis of the summer months in the cities, in 



TREATMENT. 619 

which disease there is ordinarily great irritability of the stomach. 
It is readily administered mixed with a little sugar and moistened. 
It is useful in recent as well as protracted cases. If there is no 
decided irritability of stomach or acidity of the stools, Dover's 
powder may be substituted for the powder of chalk and opium, 
and it is preferable in those cases in which the entero-colitis results 
from taking cold, and there is a strong febrile reaction. 

When the disease is chronic, and the vital powers begin to 
fail, as indicated by pallor, more or less emaciation, and loss of 
strength, the following is the best tonic mixture with which I am 
acquainted. It aids in restraining the diarrhoea, while it increases 
the appetite and strength. It should not be prescribed until the 
inflammation has assumed a subacute or chronic character. 

R . Tinct. colornbse. 5"j ; 

Liq. ferri nitratis gtt. xxiv ; 
Syr. simplic. ^iij. Misce. 

Dose, one teaspoonful every four hours to an infant of one year. 
In the Out-door Department at Bellevue we commonly give this 
tonic alternately with the bismuth powders. 

External Treatment — Some writers recommend depletion in this 
disease by leeches, advice likely to do much harm, unless the 
particular cases are described in which it may possibly be of 
service. It can be useful only in those cases in which the infant 
is robust and of full habit, and the disease commences suddenly 
with decided febrile reaction. Such cases are oftenest seen with 
us in the winter season, and even these are ordinarily best treated 
without loss of blood. Sinapisms and poultices usually are suffi- 
cient as local measures. In these cases, also, the warm mustard 
foot-bath should be employed, and repeated if there is restlessness 
or cerebral symptoms. 

In all forms of intestinal inflammation in infancy and in all its 
stages, mild counter-irritation over the abdomen is often useful, 
but vesication, by increasing the restlessness of the infant and 
reducing its strength, without materially modifying the severity 
or duration of the disease, does more harm than good. It is not 
to be thought of as a remedial measure. I have known a trouble- 
some sore continuing till death, and probably hastening this result, 
to occur from this treatment. Poultices or fomentations over the 
abdomen are sometimes beneficial, especially those of a mildly 
irritating nature. A poultice of powdered cloves, cinnamon, and 
ginger, or of linseed meal to which a little mustard is added, may 



620 ENTERITIS AND COLITIS IN CHILDHOOD. 

be employed, or, better than either, a linseed poultice spread thin, 
under which a single layer of muslin is placed, saturated with 
tincture of camphor, and over both oil silk. In the entero-colitis 
of infants, occurring in the cool months, and due to exposure to 
cold, this treatment is especially useful. In the epidemic entero- 
colitis of the summer months, which may be aggravated by 
heat, treatment by poultices may be injudicious, but in such cases 
it is proper to produce moderate redness over the abdomen by 
temporary applications. 

Some physicians believe that dentition is a cause of infantile 
entero-colitis, and advocate lancing the gums if they are found 
swollen. In my opinion, this treatment, in genuine inflammation, 
is opposed by both reason and experience. 



CHAPTER IX. 

ENTERITIS AND COLITIS IN CHILDHOOD. 

Intestinal inflammation in childhood differs materially from 
the form or type which it commonly presents in infancy. Its 
causes, symptoms, and extent differ in important particulars in the 
two periods. In childhood there is not ordinarily such extensive 
inflammation of the mucous membrane of the intestines as we have 
seen is present in the majority of cases in infancy, and it may, 
therefore, be properly treated as two diseases, according to the seat 
of the morbid process, namely, enteritis and colitis. Both, these 
affections in the child resemble so closely the form which they 
exhibit in adult life, that no extended description is needed in this 
connection. 

Causes. — These are vicissitudes of temperature, especially sud- 
den change from warm to cold, which checks the perspiration, and 
causes a determination of blood from the surface to the viscera. 
These inflammations are also caused sometimes by irritating sub- 
stances in the intestines. I have known faecal accumulations as 
well as worms to produce severe dysentery in the child, accom- 
panied by the characteristic tenesmus and muco-sanguineous stools, 
and ceasing as soon as the offending substances were expelled. 
The use of unripe or stale vegetables, if there is a strong predis- 
position to mucous inflammation, may be a sufficient cause, and 



SYMPTOMS. 621 

some of the most dangerous cases are due to the accumulation in 
the intestines of seeds and the parenchyma of fruits. But the 
most common cause is that mentioned, namely, sudden exposure 
to cold when the body is heated, a danger to which children are 
especially liable, on account of the easy disturbance of the circula- 
tory system in them, and their heedless exposure of themselves, 
unless incessantly watched. 

Enteritis and colitis are also frequently secondary diseases. They 
occur in children as complications or sequelae of the eruptive fevers, 
especially measles. 

Symptoms. — The alvine discharges in enteritis and colitis in 
childhood are such as occur in these diseases at a more advanced 
age. In enteritis they are thin and of the natural color, or occa- 
sionally green ; in colitis they are more consistent than in enteritis, 
and are largely muco-sanguineous. Sometimes in enteritis, if the 
inflammation is not intense, the diarrhoea is slow in appearing, or 
it may be slight, so as not to attract special attention. The dis- 
ease may then resemble remittent fever, for which it is at times 
mistaken. The upper part of the small intestines is less frequently 
affected than the lower. If there is duodenitis, the flow of bile is 
occasionally impeded from tumefaction at the mouth of the common 
bile-duct, and the icteric hue appears. In both enteritis and colitis 
there is abdominal tenderness, with more or less constant pain if 
the disease is severe, and in colitis, tormina, and tenesmus. The 
pulse is accelerated, the heat of surface augmented, the face 
flushed, and, except in mild cases, indicative of suffering. In 
many children at the commencement of the inflammation the 
nervous system is profoundly affected, as indicated by headache, 
stupor, twitching of the limbs, and sometimes by convulsions. The 
chief danger at the commencement of the disease is, indeed, from 
this source. Sometimes there is irritability of the stomach, and 
the food is rejected, though much less frequently than in the 
intestinal inflammation of infancy. Anorexia and thirst are com- 
mon symptoms. If the inflammation continue, there is soon per- 
ceptible emaciation, with loss of strength. The eyes become 
hollow, the face pale, and the surface cool. Death may occur at 
an early period, the vital powers succumbing from the intensity 
of the inflammation. In other cases, the acute disease ends in a 
subacute or chronic inflammation ; the patient becomes gradually 
more reduced, till he dies in a state of extreme emaciation, such 
as we often observe in the entero-colitis of infancy, or from this 
state he may recover by degrees, though perhaps with an irritable 



622 ENTERITIS AND COLITIS IN CHILDHOOD. 

state of the bowels, which continues for months. In a majority of 
cases, however, enteritis and colitis in childhood, if not neglected 
soon begin to yield, and terminate favorably in one or two weeks. 

Diagnosis. — It is not difficult to determine the existence of the 
inflammation. This is indicated by the fever, abdominal tender- 
ness, and the relaxed state of the bowels. "Whether the disease is 
enteritis or colitis is determined by the character of the stools, the 
seat of the tenderness, and the presence or absence of tenesmus. 

Prognosis. — It has been stated above that enteritis and colitis 
in children commonly terminate favorably. The result depends 
not only on the extent and severity of the inflammation, but the 
constitution and previous health. The inflammation is more seri- 
ous when secondary than when primary. Extensive and great 
tenderness of the abdomen, features pale, anxious, and indicative 
of suffering, pulse frequent and feeble, should excite the most 
serious apprehensions. Frequent vomiting also denotes a grave 
form of the disease. Stupor, and especially convulsive movements, 
show that the nervous centres are affected, and should make us 
guarded in the prognosis. Improvement in the disease, on which 
to base a favorable prognosis, is apparent in the diminution of the 
tenderness, improvement in the pulse and character of the stools, a 
more cheerful countenance, and less disrelish of food. 

Treatment. — This should be similar to that employed in the 
adult. In enteritis at the commencement of the disease, if there 
is reason to suspect the presence of any irritating substance in the 
intestines, and ordinarily in colitis, it is advisable to commence 
treatment by the use of some simple evacuant, like castor oil. 
After this our reliance, so far as internal treatment is concerned, 
must be mainly on opiates, or opiates with diaphoretics. Qne of 
the best remedies of this class is the Dover's powder, which may 
pe given to a child five years old in doses of three grains every 
three hours. A corresponding dose of any of the other opiates may 
be given, but with less sudorific effect. In colitis the occasional 
administration of a laxative should not be neglected, if the stools 
are entirely or mainly muco-sanguineous. It should be employed 
so as to prevent accumulation of fsecal matters in the colon, which 
would serve as an irritant and increase the inflammation. The 
dose should be small, merely sufficient to produce a foecal evacua- 
tion, and repeated as required, daily or less frequently. The 
laxative commonly preferred is Eochelle salts or castor oil. The 
physician may prescribe an opiate mixture containing sufficient 
of the laxative to have the effect desired, though ordinarily it is 



TREATMENT. 623 

better to prescribe the two separately, so that the laxative can be 
given or withheld, according to circumstances, while the opiate is 
continued more regularly. 

When the stage of active inflammation has passed, if there is 
still looseness of the bowels, astringents should be employed in 
connection with the opiate. The tincture of catechu or kino may 
be given with an equal quantity of paregoric. The subnitrate of 
bismuth in doses of from five to ten grains in combination with 
Dover's powder or other opiate will also be found useful. 

Acetate of lead with opium, so much used in adult cases, is 
equally serviceable in children. One grain may be given to a child 
of five years with one-third of a grain of opium. Injections 
properly administered aid in controlling the inflammation. Those 
containing opium are especially serviceable in relieving the 
tenesmus of dysentery. When the stomach is irritable, or when it 
is desired to use a medicine like tannic acid, which is unpleasant 
to the taste, it is often best to administer it in the form of enemata 
or suppositories. 

Local treatment is highly important in the enteritis and colitis 
of childhood. Leeches in the commencement of the inflammation 
have a good effect in moderating its intensity. If the disease is 
secondary, or there is scrofula or a state of feebleness, depletion is 
contra-indicated. 

Apart from leeching, the local treatment should consist in the 
use of emollient applications covered with oil-silk, and made 
sufficiently irritating by mustard or otherwise to cause constant 
redness. 

If there are symptoms threatening convulsions, a mustard foot- 
bath repeated occasionally will usually tranquillize the nervous 
system and avert the danger. 

The diet should be bland and unirritating. In the first stages 
of the inflammation, rice or barley-water, or arrowroot boiled in 
water, and similar drinks should constitute the main diet. "When 
the active inflammation has abated, and at any period of the dis- 
ease if there is a tendency to prostration, more nourishing food 
should be given. Milk and animal broths may then be allowed. 
In cases which are protracted, or attended with symptoms of 
exhaustion, alcoholic stimulants are required. 



624 CHOLERA INFANTUM 



CHAPTER X. 

CHOLERA INFANTUM. 

Cholera infantum, or, as it is sometimes called, choleriform 
diarrhoea, is a disease of the summer months ; and, with excep- 
tional cases, of the cities. It receives the name which designates 
it from the violence of its symptoms, which closely resemble those 
in Asiatic cholera. It is, however, quite distinct in its nature, 
occurring independently of the epidemics of that disease. Post- 
mortem examinations establish the fact that it is a non-inflamma- 
tory diarrhoea, but on account of the violence and striking character 
of its symptoms, and its great mortality, it is proper to describe it 
as a distinct disease. 

I have elsewhere stated that, as regards at least this city, the 
term cholera infantum has been so extended as to embrace a large 
part of the diarrhceal maladies affecting infants in the summer 
months. Some physicians apply it even to mild but protracted 
cases of ordinary non-inflammatory or inflammatory diarrhoea 
occurring in the season mentioned. I employ it, and it should, in 
my opinion, only be employed, to designate that form of infantile 
diarrhoea in which there are frequent watery, perhaps serous stools, 
accompanied by vomiting and rapid and great emaciation. More- 
over, when the disease ceases to be of this character, the term 
cholera infantum should no longer be applied to it, but it should 
receive another name indicative of the pathological state which 
has supervened. Intestinal inflammation frequently succeeds 
cholera infantum, and certain writers describe it as a stage of that 
disease. Properly, the inflammation should be regarded as a dis- 
tinct affection, just as the enteritis, which sometimes results from 
cholera morbus, is not considered as a stage of that disease, but as 
a disease in itself. 

The number of deaths from cholera infantum reported in our 
bills of mortality is so large, while the number from the same 
disease embraced in the death statistics of European cities is so 
small comparatively, that some have been led to believe that this 
affection, whether termed cholera infantum, or, as by French 



CAUSES — SYMPTOMS. 625 

writers, choleriform diarrhoea, is much more prevalent and fatal in 
this country than in Europe, whereas, were these terms employed 
in all places to designate precisely the same disease, probably no 
great difference would be found in the prevalence of cholera 
infantum on the two sides of the Atlantic. 

Causes. — It has been stated that cholera infantum prevails 
mainly in the cities and in the summer months. Cases occur from 
the month of May to October. Its maximum frequency and 
severity correspond with the degree of heat, and it is therefore 
most prevalent in the months of July and August. One of the 
chief causes of this disease *is, doubtless, residence in an atmosphere 
loaded with noxious vapors, especially gases arising from animal 
and vegetable decomposition, or an atmosphere rendered impure 
by overcrowding and by personal and domiciliary uncleanliness. 
It is, therefore, much more common in tenement-houses and parts 
of the city occupied by the poor than in cleaner and less crowded 
streets and apartments. 

Summer heat and the anti-hygienic conditions to which it gives 
rise in the cities, sometimes appear to be sufficient in themselves 
to develop cholera infantum ; at least it occurs without other 
obvious cause. In other, and probably the majority of cases, 
another cause co-operates, namely, the use of improper food. 
Atmospheric heat and its depressing influences are then predis- 
posing causes, while the use of indigestible or irritating food is the 
exciting cause. Infants upon whom both causes are operative are 
most liable to cholera infantum in its severe form. Hence bottle- 
fed infants of the city are especially liable to it, and infants whose 
food is carelessly and improperly prepared. Often in the hot 
months, acid and indigestible fruits, as currants, heedlessly given 
to an infant, occasion the attack. 

Cholera infantum occurs commonly under the age of two years. 
It is so frequent during the period of first dentition, that some 
writers consider dentition a cause. At this period, however, as 
has been stated elsewhere, there is great functional activity, and 
rapid development of the intestinal follicles, and the peculiar 
liability to cholera infantum at this age should be attributed to 
this cause rather than to dentition. 

Symptoms. — Cholera infantum sometimes commences abruptly, 
the previous health having been good. In other cases it is pre- 
ceded by a premonitory stage, that of simple diarrhoea. The stools 
are thinner than natural, and somewhat more frequent, but not 
such as to excite alarm. Suddenly the evacuations become more 
40 



626 CHOLERA INFANTUM. 

frequent and watery, and the parents are surprised and frightened 
by the rapid sinking and real danger of the infant. Occasionally 
this antecedent diarrhoea has continued several weeks, attended 
with emaciation, and associated, perhaps, with intestinal inflam- 
mation. 

This disease is characterized by the discharge of thin stools, 
designated by some watery, by others serous. The first evacuations, 
unless there has been previous diarrhoea, contain considerable faecal 
matter. They are so thin as to soak into the diaper almost like 
urine, and in some cases they scarcely produce more of a stain than 
does this secretion. The odor is peculiar, not fsecal, but musty 
and offensive; occasionally the stools are almost odorless. Com- 
mencing simultaneously with the watery evacuations, or soon after, 
is another symptom, namely, irritability of the stomach, which 
increases greatly the prostration and danger. "Whatever is swal- 
lowed by the infant is rejected immediately, or after a few minutes, 
or there may be retching without vomiting. The appetite is lost, 
and the thirst is intense. Cold water, especially, is taken with 
avidity, and if the infant nurses, it eagerly seizes the breast, in 
order to relieve the thirst. The tongue is moist at first, and clean 
or covered with a light fur. The pulse is accelerated, while the 
respiration is either natural or somewhat increased in frequency ; 
the surface is warm, but its temperature is speedily reduced. 
There is no abdominal tenderness, and no evidence of pain. The 
infant is often restless at first, but its restlessness is due to thirst, 
or that unpleasant sensation which the sick experience when the 
vital powers are rapidly reduced. The urine is scanty in propor- 
tion to the gravity of the attack. 

The loss of strength and the emaciation are more rapid than in 
any other diarrhoeal malady, except Asiatic cholera, and the most 
severe form of cholera morbus. The parents scarcely recognize in 
the changed and melancholy aspect of the infant any resemblance 
to the features which it exhibited a day or two before. The eyes 
are sunken, the eyelids and lips are permanently open from the 
feeble contractile power of the muscles which close them, while the 
loss of the fluids from the tissues and the emaciation are such that 
bony angles become more prominent, and the skin in places lies in 
folds. 

As the disease approaches a fatal termination, which often occurs 
in two or three days, the infant remains quiet, not disturbed even 
by the flies which alight upon its face. The limbs and cheeks 
become cool; the eyes bleared, and pupils contracted. A state of 



ANATOMICAL CHARACTERS. 627 

stupor results, from which there is no relief, and which after a few 
hours ends in death. 

Often, even in cases which are ultimately fatal, there is not such 
a speedy termination of the disease. The choleriform diarrhoea 
ends in inflammation, which runs a protracted and obstinate course. 
The disease then becomes the entero-colitis, inflammatory diarrhoea, 
or intestinal inflammation of writers. 

In the most favorable cases of cholera infantum the patient re- 
covers before the supervention of inflammation. 

Anatomical Characters. — Rilliet and Barthez, who of foreign 
writers treat of this disease at greatest length, describe it under 
the name of gastro-intestinal choleriform catarrh. "The perusal," 
they remark, "of the anatomico-pathological description, and es- 
pecially the study of the facts, show that the gastro-intestinal tube 
in subjects who succumb to this disease may be in four different 
states : (a), either the stomach is softened without any lesion of 
the digestive tube ; (6), or the stomach is softened at the same time 
that the mucous membrane of the intestine, and especially its fol- 
licular apparatus is diseased ; (c), or the stomach is healthy whilst 
the follicular apparatus, or the mucous membrane, is diseased ; (d), 
or, finally, the gastro-intestinal tube is not the seat of any lesion 
appreciable to our senses in the present state of our knowledge, or 
it presents lesions so insignificant that they are not sufficient to 
explain the gravity of the symptoms. 

"So far the disease resembles all the catarrhs, but what is special 
is the abundance of the serous secretion, and the disturbance of 
the great sympathetic nerve. 

"The serous secretion, which appears to be produced by a per- 
spiration (analogous to that of the respiratory passages and of the 
skin) rather than by a follicular secretion, shows, perhaps, that 
the elimination of substances is effected by other organs than the 
follicles ; perhaps, also, we ought to see a proof that the materials 
to eliminate are not the same as in simple catarrh. Upon all these 
points we are constrained to remain in doubt. "We content our- 
selves with pointing out the fact." 

American writers very generally divide cholera infantum into 
three stages, the first characterized by turgescence of the intestinal 
follicles without inflammation, but perhaps attended by more or 
less softening of the mucous membrane. In the second stage intes- 
tinal inflammation is present. The mucous membrane of the in- 
testines is vascular in patches and streaks, sometimes thickened, 
and the solitary glands and patches of Peyer are inflamed, and oc- 



628 CHOLEKA INFANTUM. 

casionally certain of them are ulcerated. In the third stage the 
brain is involved. The cranial sinuses, veins, and capillaries of 
the brain are congested, and there is transudation of serum upon 
the surface of the brain or in the ventricles. But the second and 
third stages of these writers pertain, in my opinion, as I have 
already said, to entero-eolitis, a supervening disease, and distinct 
from cholera infantum. The anatomical character of the first 
stage alone is that of cholera infantum, as the disease is understood 
by us. In our restricted use of the term, the appreciable lesions 
in cholera infantum are seen to be similar to those in the common 
forms of non-inflammatory diarrhoea. The following observations 
show the character of these lesions: — 

On the first of August, 1861, I made an autopsy of an infant 
sixteen months old, who died of cholera infantum, with a sickness 
of less than one day. The examination was made thirty hours 
after death. Nothing unusual was observed in the brain, except, 
perhaps, a little more than the ordinary injection of vessels at the 
vertex; no disease of stomach and intestines except enlargement 
of the patches of Peyer as well as the solitary glands ; mucous 
membrane pale. In this and the following cases there was appa- 
rently slight softening of the intestinal mucous membrane; but 
whether it was pathological or cadaveric is uncertain, as the 
weather was very warm. The liver seemed healthy. Examined 
by the microscope, it was found to contain about the normal amount 
of oil-globules. 

The second case was that of an infant seven months old, wet- 
nursed, who died July 26th, 1862, after a sickness also of about 
one day. He was previously emaciated, but without any definite 
ailment. The post-mortem examination was made on the 28th. 
The brain was somewhat softer than natural, but was otherwise 
healthy. There was no abnormal vascularity of the membranes 
of the brain, and no serous effusion within the cranium. The 
mucous membrane of the intestines was of healthy appearance 
throughout, except that the solitary glands of the colon were 
enlarged. The patches of Peyer were not distinct. 

At the New York Prostestant Episcopal Orphan Asylum, an 
infant twenty months old, previously healthy, was seized with 
cholera infantum on the 25th of June, 1864. The dejections, as is 
usual in that disease, were frequent and watery, and attended by 
obstinate vomiting. Death occurred in slight spasms, in thirty- 
six hours. The exciting cause was apparently the use of a few 
currants, which were eaten in a cake the day before, some of which 



ANATOMICAL CHARACTERS. 629 

fruit was contained in the first evacuations. The brain was not 
examined. The only pathological changes which were observed 
in the stomach and intestines were slight vascular patches in the 
small intestines, scarcely sufficient to be considered inflammatory 
or even congestive, and an unusual prominence of the solitary 
glands in the colon. These glands resembled small beads imbed- 
ded in the mucous membrane. The lungs in the above cases were 
healthy, excepting hypostatic congestion. 

The lesions in the above cases obviously lacked those characters 
which indicate an inflammatory disease. The observations of 
others correspond with our own in reference to these severe and 
suddenly fatal cases. 

Dr. Hallowell, in a paper on this disease published in the Ameri- 
can Journal of the Medical Sciences, July, 1847, says of the anatomical 
characters of the first stage : " These consist in an undue develop- 
ment of the follicles, both of the stomach and intestines, or of one 
of those organs, without inflammation of the mucous membrane." 

Dr. E. H. Parker, in a paper read before the New York State 
Medical Society, February 4th, 1857, says : " "When death occurs 
from the exhaustion produced by the profuse vomiting and diar- 
rhoea, a condition to which is given in this country the name of 
cholera infantum, we find the intestines to contain more or less of 
a soft, usually light yellow fsecal matter, and the stomach a fiuid 
resembling a thin gruel. The walls of the stomach are natural, 
unless the epithelial lining be a little too easily removed, the epi- 
thelial lining of the small intestines and sometimes of the large 
being in a similar state. The walls of the intestines are almost 
translucent, bloodless and apparently thin. Throughout their whole 
extent the solitary and agglomerated glands are very prominent, 
setting up almost like beads upon the surface." 

Both these writers, as well as Stewart in his monograph on 
cholera infantum, admit the frequent termination of the patho- 
logical state just described, in other words, of cholera infantum, 
according to our restricted use of the term, in entero-colitis. Most 
writers, as we have elsewhere stated, regard the entero-colitis as 
an advanced stage of cholera infantum. I believe that the opinion 
of writers is correct, that there is usually in chlorea infantum soft- 
ening of the gastro-intestinal mucous membrane, at least in places. 
But as the autopsies in this disease are made in the warmest 
weather, and after the lapse of several hours, it is difficult to de- 
cide how much of this change pertains to this disease and how 
much is post-mortem. 



630 CHOLERA INFANTUM. 

"With, the exception of the organs of digestion, no uniform lesion 
is observed in any of the viscera, unless such as is due to change 
in the quantity and fluidity of the blood, and in its circulation. 
Writers describe an anaemic appearance of the thoracic and abdomi- 
nal viscera, and occasional passive congestion of the cerebral ves- 
sels. The cerebral symptoms often present towards the close of 
life in unfavorable cases of cholera infantum may arise from a 
state of the brain similar to, if not identical with, spurious hydro- 
cephalus, which state is not attended by any uniform or certain 
lesion of this organ. As the urinary secretion is scanty or sup- 
pressed, cerebral symptoms may in certain cases be due to uraemia. 

Diagnosis. — This disease is diagnosticated by the symptoms, 
and especially by the frequency and character of the stools. The 
stools have already been described as frequent, often passed with 
considerable force, deficient in faecal matter, and thin, so as to soak 
into the diaper almost like urine. The vomiting, thirst, rapid 
sinking, and emaciation serve to distinguish cholera infantum 
from other diarrhceal affections. 

When Asiatic cholera is prevalent, the differential diagnosis of 
the two diseases is difficult if not impossible. 

Prognosis. — This is one of those diseases in regard to which 
physicians often injure their reputation by not giving sufficient 
notice of the danger, or even by expressing a favorable opinion, when 
the case soon after ends fatally. A favorable prognosis should 
seldom be expressed without qualification. If the urgent symp- 
toms are relieved, still there is danger of the occurrence of intes- 
tinal inflammation, which, in hot weather, is formidable and often 
fatal. If the stools become more consistent and less frequent, 
without the occurrence of cerebral symptoms, we may confidently 
express the opinion that there is no present danger. 

The duration of true cholera infantum is short. It either ends 
fatally, or it begins soon to abate and ceases, or it is transformed 
into an inflammation. Death may occur, in twenty-four or forty- 
eight hours, in a state of collapse, from the frequency of the stools, 
or not till after three or four days. In general, if the patient is 
not relieved in three or four days, entero-colitis commences. 

Treatment. — The frequency and watery character of the stools 
in cholera infantum, and the consequent rapid sinking of the 
infant, call for prompt measures for the arrest of the disease. If 
there is any irritating substance in the stomach or intestines, 
which acts as an exciting cause of the vomiting or diarrhoea, or at 
least aggravates it, it is proper to commence treatment by the use 



TREATMENT. 631 

of some evacuant. Dr. James Jackson {Letters to a Young Physi- 
cian) says: "In the acute attacks of cholera infantum, the first 
object is the dislodgement of offending materials from the alimen- 
tary canal. In most cases the spontaneous efforts suffice to clear 
the stomach. But, occasionally, it is evident that these efforts fail 
to remove a load which the patient has imprudently been per- 
mitted to take into the stomach. Then small doses of ipecacuanha 
may be given with benefit till the burden is thrown off. Two to 
four grains will usually suffice. Much more frequently the efforts 
of the bowels are not successful in carrying off their contents, and 
the stomach is at the same time so irritable as not easily to retain 
medicine. Then calomel is the great remedy. "Whatever objec- 
tions theoretical men may make to the use of so potent a drug 
for a tender infant, few practical men, after having tried it, 
are willing to treat this disease without this article. It is not 
offensive to the taste; it can be retained when scarce any other 
medicine can be ; and, if vomiting follows a dose of it, the stomach 
becomes less irritable, so that a way is open for other medicines or 
for nourishment. By its operation the bowels are disburdened of 
their load with benefit. But it is a medicine which is slow in its 
operation, and castor oil may be used after it with advantage." 

Unless the stomach is quite irritable, castor oil, syrup of rhubarb, 
or, if there is a state of acidity, rhubarb and magnesia, are generally 
sufficient to remove the indigestible substance. Dr. E. H. Parker 
prefers the syrup of rhubarb in such cases. If the stomach is irri- 
table, so that the purgatives mentioned would be vomited, calomel 
is certainly the best medicine. This should not be given to the 
extent of more than one or two doses, and it may be aided by a 
simple enema. 

If there is no indigestible substance in the intestines, purgatives 
should not be used, as they would then do more harm than good. 
If the disease has continued several hours, it is probable that any 
irritating substance, which might have been present at first, has 
passed from the bowels, and no purgative is required. 

Treatment designed to diminish the frequency of the evacuations 
and improve their character, should be commenced at the earliest 
moment. 

Every hour that cholera infantum continues unchecked reduces 
the strength of the infant and diminishes his chance of recovery. 
Our main reliance must be on opium in some form. Dr. Jackson 
truly remarks that we have no substitute for it. "Erom three to 
live drops of the tincture of opium," says he, "may be given, and 



632 CHOLERA INFANTUM. 

the dose may be repeated in eight or twelve hours." This he 
recommends "after the bowels are unburdened." 

It is better to give a smaller dose of opium and repeat it often. 
If laudanum is used, it may be given in one drop doses every two 
or three hours to a child one year old, its effect being watched. 
There is danger in this disease of the sudden supervention of 
stupor, amounting even to coma and ending fatally. In these 
cases the stools are generally suddenly checked, and the opiate 
might aid in producing this result. In a few instances which I 
can recall to mind, where death occurred in this way, the friends 
believed that the melancholy result was hastened by the medicine. 
If the evacuations are partially checked and there are signs of 
stupor, the opiate should either be omitted or given less frequently. 
Explicit and positive directions to this effect should be given. 
Eligible preparations of opium for this disease are paregoric, 
tincture of opium, pulv. cretse comp. c. opio, and, if there is no irri- 
tability of stomach, Dover's powder. 

Astringents and often alkalies are useful employed as adjuvant? 
of the opiate. The chief danger is from the frequent watery 
evacuations, and both these remedies certainly aid materially in 
restraining them. Astringents are less tolerated by an irritable 
stomach than either opium or chalk, so that it is often advisable 
to discontinue their use when they are vomited, in cases in which 
they would be very beneficial if the stomach were retentive. The 
opiate and alkali may be employed in the following combination : — 

$. Tinct. opii gtt. xij ; 

Mistur. cretse §iss. Misce. 
One teaspoonful every two or three hours to an infant one year old. To this 
mixture an astringent may be added, as tincture of catechu or kino. 

I prefer for ordinary cases, as it is astringent, alkaline, opiate, 
and anti-emetic, the powder of subnitrate of bismuth and chalk 
with opium, already recommended for intestinal inflammation. 

By this mode of treatment the stools are generally in a few hours 
rendered less frequent and more consistent. 

There are physicians who believe that calomel given in small 
and repeated doses has a beneficial effect in choleriform diarrhoea, 
but those who use it employ it in combination with opium, and it 
is probable that the good effect observed is largely due to the latter 
remedy. Erom the anatomical characters of eholera-infantum 
there is apparently no indication for a medicine that affects the 
function of the liver, and there is no evidence that calomel exerts 
any good effect on the follicular apparatus of the intestines, which, 



INTESTINAL WORMS. 633 

so far as we can localize the disease, seems to be most in fault of 
any part of the digestive apparatus. On theoretical grounds, 
therefore, I should oppose the employment of this agent, and my 
observations of its effects have been such that I entirely discard its 
use while we have other safe and efficient remedies to meet every 
indication. 

Ordinarily, as the diarrhoea is relieved, the vomiting ceases. 
The opiate and alkaline remedies employed for the former are also 
curative of the latter ; still the vomiting, if frequent and obstinate, 
sometimes does require special treatment, and there are no better 
anti-emetic mixtures than those recommended in our remarks on 
the treatment of intestinal inflammation. In robust infants at 
the commencement of the attack, small pieces of ice taken in the 
mouth aid in diminishing the irritability of stomach. Mustard 
should also be applied to the epigastrium. 

In most cases alcoholic stimulants are required. The best of 
these is Bourbon whiskey or brandy, which should be used from an 
early period of the disease. Aside from its sustaining the vital 
powers, it aids also in relieving the irritability of stomach. 

The diet in cholera infantum should be simple but nutritious. 
It should be given little at a time and often. If the infant nurse, 
it should be confined to the breast. If weaned, cold barley or 
rice-water should be given, with whiskey or brandy, in the first 
stages of the disease, and afterwards milk or broths may be em- 
ployed in addition. 

If cholera infantum end in inflammation, the treatment already 
described for that disease should be adopted. 



CHAPTER XI. 

INTESTINAL WOKMS. 

The belief has been prevalent in the profession, and is now in 
the community, that the presence of worms in the intestines con- 
stitutes a frequent disease in early life. As the pathology of in- 
fancy and childhood, and especially the means of diagnosticating 
diseases, are better understood, this idea is gradually abandoned 
by the profession. Still, intestinal worms must be considered an 
occasional cause of serious derangement or even disease, and of 
death also. 



634 INTESTINAL WORMS. 

"Worms, indeed, may exist in the intestines without any appre- 
ciable deviation in the individual from a state of health. Ordi- 
narily, however, they in time give rise to symptoms so as to require 
the use of remedies for their expulsion. 

There are five kinds of worms whose habitat is the human 
intestines, namely, the ascaris lumbricoides, ascaris vermicularis, 
or, as it is sometimes called, the oxyuris vermicularis, the tricho- 
cephalus dispar, and two species of taenia. The ascaris lumbri- 
coides, when matured, measures from five inches to about a foot 
in length. Young ones are sometimes expelled not more than 
two inches in length. The color is a reddish-brown, with a shade 
of yellow. The dead worm has a paler color. The females are in 
numerical excess of the males, and their size is also greater. The 
worm in shape resembles the common earthworm, from which it 
derives the name lumbricus. It is, however, more pointed at 
both extremities than the earthworm, and the color is a paler red. 
The tail of the male worm is curved, while that of the female is 
straight. The mouth is triangular, and is surrounded by three 
tubercles. 

The ascaris lumbricoides resides usually in the small intestines. 
It occasionally enters the stomach, from which it is vomited, or 
it crawls up the oesophagus into the fauces, from which it is soon 
removed by the efforts of the individual. Cases are on record, 
one of which Andral witnessed, in which the worm entered the 
larynx, producing suffocation and speedy death. M. Tonnelle 
also witnessed such a case. A child nine years old was suddenly 
seized with great difficulty of respiration and pain in the upper 
part of the chest. A careful examination of the thorax gave a 
negative result. Death occurred in from twelve to fifteen hours, 
and at the post-mortem examination a lumbricus was found filling 
the cavity of the larynx. M. Blandin, also, witnessed a case, 
when interne of the Hopital des Enfants. An infant was suffo- 
cated by one of these worms, which had penetrated as far as the 
right bronchus. Yery rarely they crawl from the fauces into the 
nasal passages. This worm is so strong and active, that there is 
no recess or reflexion of the mucous membrane of the digestive 
apparatus which it could possibly penetrate, in which it has not 
been found. It has been discovered in the appendix vermiformis, 
in the pancreatic duct, in the common bile-duct, and even in the 
gall-bladder. The number of these worms fouiid in the intestines 
is very various. There may be only one, or the number may be 
almost incredibly large. 



ASCARIS LUMBRICOIDES. 635 

Thus, Barrier relates the case of an infant thirty months old, 
who died in Hospital decker. It was believed to be tubercular. 
jSTumerous tumors, which could be felt in the abdomen, were sup- 
posed to be tubercular masses. On making the post-mortem ex- 
amination, the mesenteric glands were found healthy, but the in- 
testines throughout their entire extent were filled with lumbrici. 
The masses which, during life, were believed to be tubercular 
glands, were found to consist of worms. The coecum, especially, 
was greatly distended by them. The intertwining or collection in 
balls of these worms constitutes, indeed, one of the chief dangers, 
as it renders them so much the more difficult of expulsion. 

The round worm, as this worm is commonly called, possesses no 
organs of penetration, still, if the intestine is weakened by disease, 
especially by ulceration, it may, by pressure with its head, force an 
opening through which it escapes into the cavity of the abdomen, 
causing peritonitis and death. This worm is often found, whether 
single or in masses, surrounded with mucus, which serves as a 
partial protection to the intestines. 

The portion of the mucous membrane in contact with lumbrici 
is often found inflamed, either from movements of the worm, or 
from pressure of a mass of worms, or even of a single worm in a 
confined position, as the appendix vermiformis. This inflamma- 
tion, continuing and increasing, may end in ulceration, and thus 
a weakened spot be produced, which may be ruptured by simple 
pressure of the mouth of the worm. In this way are, probably, 
to be explained those apparent cases of perforation, which have led 
some observers to believe that lumbrici had actually the power of 
penetrating the healthy coats of the intestines. 

M. Guersant describes a case in which the appendix vermiformis 
was found with an opening through which two lumbrici had partly 
passed into the abdominal cavity. The effect of their impaction 
in this narrow cul-de-sac was much like that of a bean or a seed 
lodged in the same situation. 

Lumbrici are sometimes found in a most remarkable location, 
namely, in little abscesses, external to the intestines, situated 
generally in the abdominal walls. These, after a time, in cer- 
tain cases, open externally, discharging pus, one or more worms, 
and perhaps a little excrementitious matter. They result from an 
opening in the intestine, through which the worm has passed, pro- 
ducing circumscribed inflammation and an abscess, and the intes- 
tine, now relieved of the irritant, heals before the abscess reaches 
the surface. 



636 INTESTINAL WORMS. 

The mucous membrane in contact with the worm sometimes 
presents the natural appearance; in other cases, it is red, being 
evidently inflamed. 

The ascaris vermicular] s, or oxyuris vermicularis, or, as it is 
termed in the vernacular, the threadworm, is also frequent in 
childhood, and is the cause sometimes of much suffering, though 
generally of less dangerous symptoms than the round worm. Its 
habitat is the large intestine, commonly the rectum. Bremser 
states that he found it even in the coecum. This worm resembles 
pieces of white thread, and hence its common name. The female 
is larger than the male, measuring about half an inch in length, 
while the length of the male is not more than two or three lines, 
and it is proportionately more slender. It exists often in vast 
numbers in the rectum, from which it is expelled with the excre- 
mentitious matter. The head of the worm is blunt, and is furnished 
with a transparent vesicle. The tail is very slender, terminating 
in a spiral in the male, while it is straight in the female. These 
worms multiply rapidly, and they move actively their anterior 
extremity. In girls they sometimes enter the vagina, producing a 
leucorrhceal discharge. 

The trichocephalus dispar, or the long threadworm, is also found 
in the large intestine, but oftener in the caput coli or ascending 
colon than elsewhere. It measures in length one and a half inches, 
sometimes even two inches. The anterior two-thirds are slender, 
resembling in size and appearance a hair, whence its name tricho- 
cephalus. The posterior third is considerably larger than the 
anterior, being, like the ascaris vermicularis, spiral in the male and 
straighter in the female. The worm is of a light color. Children 
are less frequently affected with the trichocephalus than with the 
two kinds just described. It rarely, if ever, produces any symptoms 
or does any appreciable injury. 

The taenia, or tapeworm, is much less frequent than the round 
or threadworm. There are two recognized species, the taenia 
solium and taenia lata. These worms have minute heads, which 
are different in the two species. Their bodies consist of white 
flat segments, which are united in a different manner in the two 
species. These segments near the head are small, as if rudimental, 
but as the distance from the head increases they enlarge, till their 
full development is attained. They are quadrilateral, having, 
when fully developed, greater length than breadth in the taenia 
solium, greater breadth than length in the taenia lata. 

The taenia is an hermaphrodite, each segment containing the 



causes. 637 

reproductive organs complete. The oviduct opens in the centre of 
the flat surface in the taenia solium, upon the edge of the segment 
in the taenia lata. 

The taenia attains a great length, but its maximum of growth is 
not ascertained, as pieces are generally detached and expelled from 
time to time before the removal of the entire worm. The taenia 
lata is supposed to attain the length of about fifteen feet. The 
taenia solium is considerably longer. 

The taenia is rare in early life, but cases now and then occur. I 
have met but one case in this city under the age of five years. 
Rosen and Bremser report cases between the ages of six and eleven 
years, and Huf eland, one at the age of six months. "Wawruch 
collected 206 observations of taenia, in 22 of which the age was 
less than fifteen years ; the youngest was a girl of three years. A 
most remarkable case of taenia is reported in the Gazette Medicate 
of Paris in 1837. M. Muller was called to treat a foster child five 
days old for slight constipation. The bowels were evacuated by 
the use of rhubarb, manna, and a few grains of salt, and in the 
excrement a foot and a half of taenia were discovered. This worm 
had evidently existed during the foetal life of the infant. 

A similar case was treated by Prof. Skene, in the Long Island 
Hospital, in September, 1871, and reported by Dr. Armor in the 
New York Medical Journal. The infant was born, September 3d, of 
a hearty Irish servant girl. On the 7th it refused to nurse, and 
was observed to have a mild form of tetanus. On the 8th small 
doses of calomel having been given, followed by castor oil, two 
segments of a taenia solium were passed from the bowels, and on 
subsequent days ten more segments, after which the tetanus ceased. 
The remedies employed after September 8th were the oil of male fern 
and turpentine. The mother, who had presented no symptoms of 
taenia, was ordered an emulsion of pumpkin-seeds, which " she faith- 
fully took for twenty-four hours, at the end of which she passed 
over seventy segments of taenia." This case is interesting as 
throwing light on a possible mode of the production of taenia, 
quite different from the ordinary and recognized mode, and also as 
showing the causative relation of intestinal worms to tetanus 
infantum. 

Causes. — The vermicular disease is much more common in one 
locality than another. Thus, in Paris there are few cases, while 
in the provinces of France and many other parts of Europe it is a 
common affection. It is more common in this city among the 
children of the poor than those in the better walks of life. 



638 INTESTINAL WORMS. 

In the same region, with an identity of regimen, pursuits, and 
habits, it is sometimes common in one season, and rare in another. 
It is an interesting fact, also, as showing the influence of local 
causes, which we often cannot appreciate, that, in countries where 
the disease prevails, the relative frequency of the different kinds 
of worms is often different. Thus, in England, Holland, and Ger- 
many, the taenia solium is common, and the taenia lata rare, while 
the reverse is true of Russia, Poland, and Switzerland. 

There is often some derangement or disease of the digestive 
system, which is favorable for the growth of intestinal worms. In 
cases of continued indigestion, accompanied by irritation or sub- 
acute inflammation of the mucous surface, with an excessive secre- 
tion of mucus, worms are apt to be generated, which aggravate 
the primary affection. Children in the last stages of typhoid fever 
not infrequently pass lumbrici in the evacuations from the bowels. 

It has long been a common and correct belief that the use of 
certain kinds of food favors the development of worms. Fruits in 
excess, food of an inferior quality, or but partially cooked, remain- 
ing an unusual time unassimilated in the intestines, afford a nidus 
in which worms are very apt to appear. The same may be said 
of saccharine substances, taken in too large quantity or too fre- 
quently. An excess of food, even of good quality, is also a cause, 
since this gives rise to the predisposing condition of undigested 
nutriment in the intestines. The period of childhood is mentioned 
by writers as one of the predisposing causes. Both the round and 
threadworms occur oftenest in children between the ages of three 
and ten years, but they are not very infrequent at any age between 
the first year and puberty. 

I have witnessed a large number of autopsies of infants in the 
institutions of this city, and, although the intestines in a large 
proportion of them were examined, I can recall only one instance 
in which intestinal worms were present when death had occurred 
in the first year. This immunity is, however, in great part attri- 
butable to the simple diet of these institutions. The infrequency 
of worms in the first year of life is an important practical fact. 
The immunity is greatest, for obvious reasons, in those who are 
nourished entirely or almost entirely at the breast. 

In this city, children of the poor, living in almost total disregard 
of sanitary requirements, are especially liable to worms. This is 
attributable not only to the character of their food, which is often 
of inferior quality and poorly prepared, but also to the filthy and 
insalubrious state of the domiciles and streets in which they reside, 



SYMPTOMS. 639 

and the consequent cachexia. One of the older writers remarks that 
intestinal worms, like confervoid growths, thrive best where it is 
filthy and dark. Though such analogical reasoning is not to be 
accepted, the fact remains of the great liability to worms of those 
children who reside in insalubrious and humid localities which are 
favorable also for cryptogamic vegetation. 

Symptoms of Lumbrici. — These are in part constitutional or 
sympathetic, and in part local, due to the mechanical effect of 
these entozoa on the coats of the intestines. Writers, especially 
BAlliet and Barthez, have described the symptoms supposed to 
indicate lumbrici with minuteness. Those of a constitutional or 
sympathetic character are the following : Features sometimes 
flushed, sometimes pallid, and sometimes of a leaden hue ; lower 
eyelids swollen, and sometimes surrounded by a blue semicircle ; 
thirst, nausea, or even vomiting ; appetite diminished, or entirely 
lost, or, on the other hand, augmented ; breath foul ; papillae of 
the tongue red and projecting ; pulse accelerated and irregular. 
Rilliet and Barthez state that they observed this irregularity in 
a boy three years old, at the time he was passing a large number 
of lumbrici. The irregularity afterwards disappeared. Accele- 
ration of the pulse is one of the most common symptoms of these 
worms. The popular idea of " worm fever" has indeed a founda- 
tion in fact. This fever is often remittent and mild, but occasion- 
ally it is continuous and intense. 

The symptoms pertaining to the nervous system are important. 
In mild cases they may be absent, as when there are few lumbrici, 
and the child is robust, and over the age of five years, but in 
severe cases more or fewer of these symptoms are commonly present. 
They are dilation of the pupils, especially inequality of dilation, to 
which Munro attached diagnostic value ; strabismus, twitching of 
the muscles, clonic convulsions, somnolence, headache, neuralgic 
pains, delirium. Rarely chorea, deafness, and paralysis, it is be- 
lieved, may result. (M. Bouchut, Gaz. des Hdpitaux, 1867.) Hy- 
peresthesia of the abdominal surface was present in a case which 
I attended, and which subsided as soon as the lumbrici were ex- 
pelled. Grinding the teeth in sleep, and picking the nostrils, are 
symptoms to which families attach great value. Observations, 
however, show that, though sometimes due to worms, they more fre- 
quently have another cause. 

The local symptoms or disorders, in other words those having 
a mechanical origin, are colicky pains, experienced chiefly in the 
umbilical region ; in some patients, simple non-inflammatory diar- 



640 INTESTINAL WORMS. 

rhcea ; in others, enteritis ; and in others still, colitis ; stools some- 
times natural ; in other cases, liquid but faecal ; and in others still, 
muco-sanguineous ; flatulence. M. Davaine, at a recent period, 
made the important discovery that the faeces of patients affected 
with worms contain the ova of the particular species present, in 
large numbers. The ovum of the lumbricus is oval and granular, 
while that of the trichocephalus is spherical, with a small projec- 
tion at each end, those of the threadworm oval and irregular, and 
those of the taenia round. These ova can be seen through a lens 
magnifying 150 diameters. 

In exceptional cases, there are local symptoms due to the pre- 
sence of worms in unusual situations, such as a crawling sensation 
in the oesophagus; a sense of constriction in this tube or the 
pharynx; nausea and vomiting; a cough, especially if the worm 
has crawled to the upper part of the oesophagus ; rarely the most 
urgent dyspnoea, and probable suffocation, if a lumbricus has 
entered the larynx. 

The enteritis and colitis, to which these worms sometimes give 
rise, is ordinarily mild, but in rare instances ulceration occurs, 
which may be attended by profuse and even fatal hemorrhage. 
Occasionally very painful and dangerous constipation results from 
an accumulation of worms, in a ball or mass, too large to be ex- 
pelled, unless with much delay and suffering, preventing the pas- 
sage of faecal matter, and producing severe abdominal pains. The 
symptoms in these cases resemble closely those of intussusception. 
A marked example of constipation produced in this way occurred 
in a family with whom I am acquainted, and who then resided in 
the interior of this State. A little girl of three or four years was 
suddenly affected with obstinate constipation. The physicians 
prescribed active purgatives, calomel among others, and finally 
croton oil, and various injections, without relief. There was great 
pain, with distension of the abdomen, and death seemed inevitable, 
when, after the lapse of several days, a free evacuation occurred, 
and in the stool was a mass of worms firmly intertwined. 

Children often have lumbrici without any appreciable impair- 
ment of the general health, but their presence may intensify the 
symptoms of intercurrent diseases, and greatly increase the danger. 
Thus, I recollect two children of three and three and a half years, 
with pneumonitis, who, at the same time, had lumbrici, one passing 
in the course of a few days thirty and the other twelve of these 
entozoa. Both presented well-marked physical signs of pneumo- 
nitis, and, though they recovered, the febrile movement and nervous 



DIAGNOSIS. 611 

symptoms were apparently aggravated by the intestinal affection. 
One had convulsions in the commencement of the inflammation, 
followed by profound stupor and amaurosis, lasting two or three 
days. 

Often the symptoms clue to lumbrici coexist with those of a 
protracted and distinct intestinal disease. Thus, as we have seen, 
the intestinal secretions of typhoid fever and of chronic diarrhceal 
maladies afford a nidus for the growth of worms, and accordingly, 
at an advanced stage of these diseases, lumbrici are common. 

The symptoms produced by the ascaris vermicularis are somewhat 
different. These worms do not usually cause the fever, disturbed 
digestion, the colicky pains, or the dangerous nervous symptoms 
which arise from the presence of lumbrici. ~Hov do they, like lum- 
brici, endanger life by crawling into unusual situations. Convul- 
sions have been attributed to them, but such a result is exceptional, 
if, indeed, the cause was rightly assigned. 

The most common symptom produced by the ascaris vermicularis 
is an intense itching of the anus. This is most intense at night 
when the child is in bed. It is sometimes absent during the day, 
but it returns so regularly at night, from the increased activity of 
the worm, that it has even been mistaken for a periodical nervous 
affection, and treated as such by quinine. So eminent a physician 
as M. Cruveilhier confesses that he has made this mistake. The 
itching sometimes leads to onanism, and in the female child the 
ascaris occasionally passes from the rectum to the vagina, where it 
gives rise to leucorrhcea. 

The trichocephalus dispar and the taenia are so rare in childhood, 
that few physicians ever meet a case. The trichocephalus is said 
by some to produce no symptoms. The symptoms due to taenia in 
children are not different from those in the adult. 

Diagnosis. — Bremser long since made the remark, and it has 
been repeated by most writers on diseases of children, that there 
is no sign or symptom which affords positive proof of the presence 
of intestinal worms, except the expulsion of one or more. Late 
microscopic investigations have revealed, however, a pathognomonic 
sign, namely, the presence of ova in the faeces, which indicate not 
only the nature of the disease, but the species of the worm. 

The symptoms and disorders produced by lumbrici may all occur 
from other causes. Still, if several of them are present, and a 
careful examination discloses no other cause, the presence of worms 
should be suspected, provided the child is over the age of two 
years. The microscope may then be used for diagnosis. A little 
41 



642 INTESTINAL WORMS. 

tentative treatment, entirely safe to the child, will also deter- 
mine whether the suspicion is correct. One or two doses of medi- 
cine, administered under such circumstances, like the surgeon's 
exploring needle, may reveal the nature of the disease, and indicate 
the means of cure. 

In case of the ascaris vermicularis, the itching directs attention 
to the anus as the place of the disease, and here the offending 
entozoa may often he discovered hy the eye. 

Prognosis. — Intestinal worms produce a fatal result in only a 
small proportion of cases. The ascaris vermicularis never proves 
fatal, unless in rare instances, through convulsions. The manner 
in which death may he produced by lumbrici has already been 
pointed out. 

In general, when the nature of the disease is ascertained, the 
worms are readily expelled by treatment, and the patient restored 
to health. If then there is no complicating disease, the prognosis 
is good. 

Treatment. — Much injury has been done to children by the use 
of anthelmintics occasionally employed by physicians, but oftener 
by parents before the physician is called. Medicines of this kind 
are usually irritants, and, in many of those diseases which simu- 
late the verminous affection, but are distinct from it, there is 
already an irritated if not an inflamed state of the intestinal 
mucous surface. 

Vermifuges administered under such circumstances obviously 
do harm, and in all acute diseases in which they are not required, 
even if their action is harmless, their employment is to be regretted, 
since it consumes time which is very precious. It is thus that 
many lives are lost by the use of anthelmintic nostrums, which 
are extensively advertised and which command a ready sale, since 
the belief in the presence of worms as a frequent cause of disease 
pervades all classes of the community. 

A safe rule, followed by many physicians, and it would be much 
better if it were general, is not to give anthelmintics unless the 
child has passed one or more worms, or their ova are found in the 
faeces, and not then if the symptoms seem to be referable to a co- 
existing disease. In doubtful cases in which the symptoms re- 
semble those of worms, a purgative dose of calomel or calomel 
and rhubarb may be employed. It will generally bring away one 
or more lumbrici or a mass of ascaris vermicularis, if either species 
of entozoa is present. This purgative may be safely employed if 
there is no previous diarrhoea or debility. If after one or two 



TREATMENT. 643 

doses and a free purgation no worms are passed, anthelmintic 
remedies should not be given, for it is almost certain that no 
worms exist. 

A large number of medicines have, or have had, a reputation as 
anthelmintics. Santonin, the active principle of the European 
wormseed, is one of the best, and is much employed in this country 
and in Europe. It is nearly tasteless ; it may be given in powder, 
spread on bread with the butter. It is kept in shops in one or 
two grain lozenges, with and without calomel. It has the ad- 
vantage of easy administration, and is destructive to both the 
round and threadworm. M. Bouchut considers it preferable to all 
other remedies in the treatment of the round worm. " To children 
two years of age he administers it in doses of ten centigrammes 
(2.30 grains), and in patients above this age, the quantity is in- 
creased by five centigrammes (1.15 grains) for every additional 
year." He gives in addition occasional doses of calomel or castor 
oil. In this country santonin is usually administered in one to 
three grain doses, two or three times daily, with an occasional 
purgative. The purgative is required to aid not only in the ex- 
pulsion of the worm but also of the ova. In overdoses santonin 
causes vomiting, diarrhoea, and altered vision, so that objects ap- 
pear yellow, but in medicinal closes it produces no unpleasant con- 
sequences. Other medicines are preferable if there are symptoms 
of enteritis. For many years the anthelmintic most employed in 
this country was the pinkroot, the root of the Shigella marilandica, 
an indigenous plant. It was not only prescribed by physicians, 
but employed by families as a domestic remedy. It is apt to cause, 
if the dose is large, cerebral symptoms, as vertigo, dimness of sight, 
spasm of the facial muscles, stupor, and even convulsions. These 
effects less frequently occur if the pinkroot is given with a purga- 
tive, and it has been customary to administer it in combination 
with senna in an infusion. A half ounce of spigelia with an equal 
quantity of senna is macerated for two hours in a pint of boiling 
water, and then strained. For a child two or three years old, the 
dose is half an ounce to one ounce. So popular has this vermifuge 
been in this country, that probably a majority of the native-born 
adults in the States recollect the nauseating doses of pinkroot 
administered by anxious parents. Pharmacy now provides us 
with the same medicine in a more convenient and acceptable 
form, that of the fluid extracts. 

$. Fluid ext. spigel. f|j ; 

Fluid ext. sennse f§ss. Misce. 
One teaspoonful to a child from three to five years. 



644 INTESTINAL WORMS. 

The officinal fluid extract of spigelia and senna may be given in 
the same dose. Prof. Proctor recommended the addition of san- 
tonin to this extract. 

I£. Fluid ext. spigel. et sennae fj ; 
Santonin gr. yiij. Misce. 

This is probably the best anthelmintic that can be employed for 
the destruction of the round worm in uncomplicated cases, and it 
is also very useful in treating the ascaris vermicularis. Chenopo- 
dium is also a good anthelmintic. It is efficient, and at the same 
time one of the safest in case the mucous membrane is inflamed. 
If there is abdominal tenderness, with stools too frequent, and thin, 
or mucous, and tinged with blood, I should prefer the chenopodium 
to most of the other vermifuges. To a child of three years five 
drops of the oil may be given three times daily. It may be 
continued for a longer period than would be safe for most of the 
other vermifuges. Twice a week, during its use, a mild purgative 
should be given, as castor oil, rhubarb, or magnesia, unless the 
bowels are open. It may be given dropped on sugar or in a 
mucilaginous mixture. 

Dr. J. F. Meigs says : "I myself rarely give any other remedy 
than wormseed oil in slight and especially in doubtful cases, unless 
this has already been tried and failed. From my own experience, 
I believe that this remedy is all-sufficient in a large majority of 
the cases that occur in this city, as these are almost always of a 
mild character, and as it not only produces the expulsion of the 
parasites when they exist, but also acts beneficially upon the forms 
of digestive irritation which simulate so closely the symptoms 
produced by worms. I am persuaded, indeed, that of all the cases 
that have come under my notice, in which it seemed probable that 
worms might be present, none were expelled in nearly half, and 
yet the signs of disturbed health have passed away under the use 

of the remedy." "The following is a very good formula for 

the administration of this remedy : — 

"R. 01. chenopodii gtt. lx vel 5j ; 
P. g. acaciae 3ij ; 
Syrup, simplic. 3j ; 
Aq. cinnamom. ^ij. Misce. 
Give a dessertspoonful three times a day for three days, and repeat after several 
days." 

In cases of protracted intestinal disease attended by an increased 
and vitiated secretion from the mucous surface, a state which often 
gives rise to worms, turpentine is one of the best anthelmintics. 



TREATMENT. 645 

In fact, in some of these cases, there is no good substitute for it. 
For example, a boy of about ten years, attended by myself, 
October, 1864, had reached or nearly reached the fourth week of 
typhoid fever, when he passed from his bowels a large quantity of 
blood. He was previously emaciated and weak, and there had 
been, as is usual in such cases, considerable diarrhoea. The 
hemorrhage was attended with great prostration, from which, 
however, he partially rallied by the use of stimulants. On the 
following day an equally severe hemorrhage occurred, attended 
with coldness of the face and extremities and great feebleness of 
pulse, so that death appeared imminent. Turpentine was now 
administered every six hours, a few lumbrici were passed, and the 
case thenceforth progressed favorably. The mechanical effect of 
the lumbrici on the ulcerated surface of intestine had probably 
given rise to the hemorrhage. Turpentine may be given in doses 
of from five to ten minims three times daily to a child five years 
old. Sweetened milk or sugar in powder is a good vehicle for it, 
or it may be given in a mucilaginous mixture. 

fy. Spts. terebinth, rect. 5ij ; 
01. limonis gtt. v ; 
Mucil. gum acac., 
Syr. simplic., aa 5vj ; 
Aq. anisi §j. Misce. 
Dose, one teaspoonful every six hours. 

The following formula for the employment of this agent is 
recommended by Dr. Condie : — 

R . Mucil. gum acac. |ij ; 
Sacch. alb. 5x ; 
Spir. sether. nitr. 5iij ; 
Spir. terebinth, rect. 3iij ; 
Magnes. calcinat. 9j ; 
Aquse menthse §j. Misce. 

It is useless to enumerate the many anthelmintic mixtures which 
have been extolled from time to time. Those mentioned above 
are the least nauseous, and will rarely disappoint the practitioner. 
One other antidote for the round worm should be mentioned, as it 
has been much used and is efficient, namely, cowhage. This con- 
sists of the bristles which cover the pods of the Mucuna pruriens, 
a tropical plant. The pods are dipped in plain syrup of the ordi- 
nary consistence, and the bristles are scraped off with the syrup. 
"When enough of the medicine is added to render the syrup of the 
consistence of thick honey, it is ready for use. The dose is a tea- 
spoonful every morning for three days, after which a cathartic 



646 GASTRO-INTESTINAL HEMORRHAGE. 

should be administered. I have never prescribed cowhage, although 
it is not unfrequently ordered by physicians, and a popular nostrum 
consists chiefly of it. 

Threadworms require different treatment. The anthelmintics 
described above have less effect on them than on the lumbrici. 
Still, they may be administered for the expulsion of the former, 
but rather as adjuvants to the main treatment. The main treat- 
ment should be local, consisting in the use of injections, since from 
the habitat of this worm enemata will ordinarily reach and destroy 
it. The substances which have been successfully employed as 
enemata are salt and water, lime-water, a decoction of aloes, or a 
decoction of two cloves of garlic in milk. West recommends the 
injection of six ounces of lime-water and two drachms of tincture 
ferri chloridi. Trousseau uses a solution of the arsenite of soda. 

fy. Sodae arsenit. gr. j ; 
Aq. destillat. §xij. M. 

For six enemata, one or two daily. 

Cold injections are more effectual than warm, and even a daily 
injection of cold water has sometimes been. found sufficient to 
effect a cure with proper internal remedies. 

Threadworms in the rectum may also be destroyed by ointments 
containing mercury, as a drachm of mercurial ointment mixed 
with oil or melted butter, or five grains of calomel with the yelk 
of an egg, (Bouchut.) After the expulsion of the worms patients 
often require tonic treatment. In the treatment of taenia in chil- 
dren the pumpkin-seed is a safe and efficient remedy, and is the 
one now commonly employed. 



CHAPTER XII. 

GASTRO-INTESTINAL HEMORRHAGE. 

Hemorrhage from the capillaries is more frequent in infancy than 
at any other period of life, whether in consequence of the irregu- 
larity of the circulation and frequent congestions in the infant, 
or the greater delicacy and feebleness of the minute vessels at 
this age. Hemorrhage, generally capillary, from the gastrointes- 
tinal mucous surface, occurs sufficiently often in the child, and 
especially in the infant, to render it a disease of some importance. 
It is more frequent the younger the individual. 

This hemorrhage occurs in three distinct pathological states: 



GASTRO-IXTESTINAL HEMORRHAGE. 617 

first, in the new-born infant from causes not fully ascertained ; 
secondly, from a pathological state of the blood or the vessels in 
which it circulates, and which is often connected with purpura 
hemorrhagica ; thirdly, from a local cause. 

First Variety. — In 49 cases, which I have collected from different 
writers, the hemorrhage occurred in 38 under the age of six days, 
in 5 from six to ten days, and in 6 from ten to twenty days. Some 
authors cite cases which occurred at the age of several weeks, but 
hemorrhage into the intestines at so late a period cannot be due to 
any cause operating at birth, and it is proper to consider such as 
examples of one of the other varieties. 

Passive congestion of the gastro-intestinal mucous membrane is 
not infrequent in the new-born. Billard speaks of twenty-five cases 
without hemorrhage which he has examined. This anatomical 
state of the mucous membrane of the intestines, whether occurring 
as part of a general plethora or being simply a local affection with 
no hyperemia of other parts, evidently requires only a certain in- 
crease and hemorrhage inevitably results. 

The cause of the abnormal congestion of the gastro-intestinal 
mucous membrane, so common in the new-born, has been referred 
by writers to the previous health of the parents, to circumstances 
attending the birth, especially too prompt a ligature of the cord, 
to irritant matters in the intestines, to external violence, and to the 
two opposite extremes, namely, a plethoric and a feeble state. In 
my opinion, the chief cause, in many cases, is the tardy or incom- 
plete establishment of the respiratory and circulatory functions, 
which gives rise to congestion in the cavities of the heart and in the 
lungs, and, consequently, in the capillaries of the systemic system. 
Evidently, this congestion is most intense in the full-blooded. Bil- 
lard says, of fifteen cases of intestinal hemorrhage which he ex- 
amined, most of them were remarkable for the plethoric condition 
of their bodies and the general congestion of their integuments. 
Some, on the contrary, were pale and feeble, as is common after 
abundant hemorrhage. 

In two infants who died soon after birth, and whose bodies I 
subsequently examined, there was apparently a plethoric state, 
which rendered the fatal result more certain, if it did not, indeed, 
produce it. In one of these, in addition to intense general conges- 
tion, meningeal apoplexy had occurred, although the birth of the 
child had been easy. 

It is not difficult to understand in what way too speedy a liga- 
ture of the cord may be a cause of capillary congestion and 



648 GASTRO-INTESTINAL HEMORRHAGE. 

hemorrhage. At the moment of birth, the uterus is contracted, 
the placenta compressed, and, if the cord is now tied, more blood 
remains in the vessels of the infant than if tied a little later. A 
little later, in consequence of the temporary cessation of uterine 
contractions, and the re-establishment of circulation in the infant, 
blood flows through the cord towards the placenta. The cord 
thus acts as a safety valve to the circulation. Any accoucheur 
who will take pains to witness the effect on the cord of the return 
of circulation, will observe what I have stated. Too speedy a 
ligature of the cord would not, however, be sufficient in the ma- 
jority of cases to produce that amount of plethora which would give 
rise to intestinal hemorrhage without other co-operating causes. 

Tardy or incomplete establishment of respiration and circula- 
tion, which gives rise to intestinal congestion and hemorrhage, 
may be due to disease of the heart or lungs, as atelectasis or 
cyanosis, to feebleness of the infant, or to slow and difficult birth. 
In a large proportion of cases, however, the birth is easy. Thus, 
three of five patients with intestinal hemorrhage, who were treated 
by M. G-endrin, were born of an easy labor, and the same was true 
of four infants observed by M. Kiwisch. 

The second variety of gastro-intestinal hemorrhage often occurs 
as a sequel of other and debilitating diseases. I have known it 
to occur as a sequel of measles, smallpox, scarlet fever, and in one 
case of typhoid fever. One of these patients, when apparently 
the period of danger was passed, began to lose blood from nearly 
all the mucous surfaces, from the nostrils and gums, as well as 
intestines, and the case, which but for the hemorrhage would 
doubtless have had a favorable issue, terminated fatally in less 
than a week. 

Patients with this variety "of gastro-intestinal hemorrhage some- 
times present the maculae of purpura, and commonly their aspect 
is pallid and cachectic. The following was a fatal case of hemor- 
rhage occurring from the ileum, in a mild form of purpura hemor- 
rhagica : — 

Case. — An infant, eight months old, of healthy parentage, nursing, 
with no previous sickness, and fleshy, vomited a small quanty of blood 
on the 25th of March, 1865; soon after it passed a stool consisting of 
almost pure blood. On the following day five or six patches of pur- 
pura hemorrhagica were observed on the arms and legs. These maculae 
continued till death. There was no more hsematemesis, but the stools, 
which were from two to four daily, consisted largely of blood. Death 
occurred from exhaustion on March 31st. 

Sectio Cadaver. — Head not examined; thoracic organs healthy, but 
pale; liver fatty; stomach, upper part of small intestines, and entire colon 



GASTROINTESTINAL HEMORRHAGE. 649 

of normal appearance, unless presenting a somewhat lighter color than 
the healthy intestine from deficiency of blood; mucous membrane in 
the ileum to the extent of several inches, intensely injected without 
thickening. The blood had obviously escaped from this portion of the 
intestine, and a moderate amount of this fluid was found in the tube 
below the point of vascularity. This case is interesting not only on 
account of the development of purpura hemorrhagica, but the subse- 
quent melasna in a nursing child, apparently of healthy parentage, and 
without previous sickness. 

In our remarks on internal convulsions, the case is related of a 
scrofulous infant who, to all appearance in her ordinary health, 
suddenly became affected with intestinal hemorrhage in connec- 
tion with external and internal convulsions. A point of interest 
in this case was the relation of the hemorrhage to the neurosis. 
In one of the three cases of intestinal hemorrhage described by 
West, there were also convulsions. In rare instances there is an 
hereditary hemorrhagic diathesis to which the melsena is attribu- 
table. In the New York Journal of Medicine and Surgery, July, 
1840, Prof. Swett relates the history of a hemorrhagic family. 
Seventeen out of eighteen children of this family had died of 
hemorrhage of one form or another, and the survivor had epistaxis 
and melsena. 

In the third variety, among the local causes producing hemor- 
rhage may be mentioned ulceration as in typhoid fever, or in 
severe intestinal inflammation, the mechanical effect of solid sub- 
stances, lumbrici, invagination, obstruction to the portal circula- 
tion, polypus of the rectum. Occasionally at the post-mortem 
examination of young infants I have found blood with mucus in 
the duodenum and jejunum, these portions of the intestines being 
at the same time intensely congested. In one case of protracted 
entero-colitis occurring in the summer season, I found many small 
circular ulcers in the colon, nearly all containing points of extra- 
vasated blood. Such are the principal local causes of hemorrhage 
from the bowels. Ordinary colitis may also be considered a cause, 
although the amount of blood evacuated in this disease is commonly 
small. 

Of the three forms of intestinal hemorrhage described above, 
that arising from local causes is most frequent, while tbat occur- 
ring from a purpuric or hemorrhagic diathesis is least frequent. 
In rare cases fatal intestinal hemorrhage may occur in the new- 
born, and the blood be retained in the intestine, or if passed it 
may so closely resemble the meconium that its true nature is not 
discovered. M. Bednar relates the following case (Krankheiten 



650 GASTRO-INTESTINAL HEMORRHAGE. 

der Neugebornen): "On the eleventh, day after birth the boy's 
skin (then of a pale yellow color) diminished in warmth, the im- 
pulse of the heart became dull and prolonged, the respiratory 
murmur scarcely perceptible. The child lay almost motionless 
and slumbering. The day following the surface could scarcely 
be kept warm, and the little patient had to be aroused to suck. 
On the twentieth day after birth it died. The brain was found 
to be ansemic, the lungs plethoric, whilst blood was effused into 
the duodenum and stomach." 

, Melsena is more frequent than hsematemesis. The hemorrhage, 
except when produced by a local cause, is usually from the small 
intestines. The blood, unless it comes from a point near the 
anus, as the rectum or descending colon, is commonly dark, and 
sometimes partially decomposed, emitting an offensive odor. Ad- 
mixture of the blood with the intestinal secretions prevents coagu- 
lation of the fibrin. 

Gastro-intestinal hemorrhage in itself produces few symptoms 
aside from the prostration which attends all hemorrhages. The 
disease with which it is associated may give rise to many and 
severe symptoms. 

Prognosis. — The result in the first and second varieties is much 
more unfavorable than in the third. Many new-born infants 
affected with gastro-intestinal hemorrhage die, but some recover. 
Eillard attended fifteen fatal cases. It is probable, however, that 
death in the first variety is often due more to some coexisting 
lesion, than to the intestinal hemorrhage. Meningeal apoplexy, 
and the incomplete establishment of the circulatory and respiratory 
functions, may both operate as direct causes of death in this variety. 

In the second variety, also, a very guarded prognosis should 
be given ; so great a change in the circulatory system as to cause 
rupture of the capillaries, or transudation of blood in the ordi- 
nary course of the circulation, is a serious state. "When this he- 
morrhage occurs as a sequel of the eruptive fevers, or in purpura 
hemorrhagica, the patient is more apt to die than recover. 

In the third form of intestinal hemorrhage, the result depends 
on the nature of the cause, whether it is susceptible of removal. 
The majority of cases in this variety recover. 

Treatment. — Billard recommends, as a means of preventing ca- 
pillary congestion and hemorrhage in the new-born, to allow a 
little blood to escape from the umbilical cord before its ligation, 
if the establishment of respiration and circulation is difficult or 
incomplete. This relieves the hyperemia of the internal organs 



TREATMENT. 651 

and facilitates the flow of blood. After the commencement of 
internal hemorrhage and the appearance of bloody stools, the same 
may be done if plethora is indicated by the florid and robust ap- 
pearance of the infant, and the cord is not too much shrivelled. 

The treatment, both therapeutic and regimenal, of intestinal 
hemorrhage should vary according to the age and state of the 
infant, the profuseness of the hemorrhage, and the nature of the 
cause. Perfect quietude, in the recumbent position, is requisite 
in all severe cases. Derivation to the extremities should be pro- 
cured in the young infant, by heated dry flannel or flannel wrung 
out of hot water ; in the older infant, by the same, with the addi- 
tion of mustard. The nursing infant should remain at the breast, 
being allowed, perhaps, in addition to the breast milk, a little cool 
barley or gum- water. Spoon-fed infants should be given food of the 
blandest quality, in the liquid form and cool. This is the proper 
diet, whatever the age, in the commencement of the hemorrhage. 
If there are evidences of exhaustion, cool beef-tea, or essence, and 
alcoholic stimulants, are necessary. It has been advised, in certain 
forms of intestinal hemorrhage, to apply leeches over the abdomen 
or around the anus. This treatment would, in my opinion, rarely 
be useful, but, on the contrary, in most cases, injurious. Hemor- 
rhage from a mucous surface, when once established, will generally 
quickly relieve the local hyperemia, and leeching, unless very 
cautiously employed, would promote the prostration, in which the 
real danger in this disease consists. On the other hand, moderate 
counter-irritation over the abdomen may be attended with real 
benefit as a derivative. 

The therapeutic treatment consists mainly in the use of astrin- 
gents. Of the mineral astringents, acetate of lead and nitrate of 
silver have been used, but the liquor ferri subsulphatis is preferable 
to all other astringents in hemorrhage from the stomach and upper 
part of the small intestine, but it is believed to be decomposed in 
its passage through the intestine, so that it has less astringent or 
styptic effect in the lower bowel than gallic acid. It may be given 
to a child five years of age, in doses of three or four drops in 
sweetened water or in mucilage. 

Astringent enemata are sometimes useful. M. Rilliet treated a 
case which recovered with enemata, each containing twelve grains 
of extract of rhatany, a strong decoction of the same astringent 
being applied externally to the abdomen. M. Bouchut recommends 
"cold water externally to the abdomen, internally by the mouth, 
or by enemata frequently repeated. These enemata should be 



652 INTUSSUSCEPTION. 

composed of two or three large spoonfuls only. They may be 
rendered more active with three grains of tannin, or with seven 
grains of the extract of rhatany, or seven grains of catechu, or, 
lastly, with one grain of nitrate of silver. In this latter, case, a 
small glass syringe and distilled water must be used, to avoid the 
premature decomposition of the medicine." 

In the hemorrhage occurring in purpura, or after exhausting 
constitutional diseases, tonics should be given in addition to astrin- 
gents. In chronic inflammatory disease of the intestinal mucous 
membrane, attended by a vitiated secretion of the follicles, the 
hemorrhage may be best treated by turpentine. I have elsewhere 
related two cases of recovery by the use of this agent, in one of 
which (typhoid fever) lumbrici were expelled. 

If the hemorrhage is due to a local cause, as lumbrici or a rectal 
polypus, the treatment obviously should consist in the removal of 
this cause. 



CHAPTER XIII. 

INTUSSUSCEPTION. 

Intussusception, or the passage of one portion of intestine into 
another, has long been known as an occasional accident. Hippo- 
crates, though debarred from the study of morbid anatomy, 
appears to have had a pretty clear idea of this lesion, and his 
practical mind suggested a mode of treatment which has been 
employed till the present time. 

Intussusception without Symptoms. 

This is not properly a disease. It consists in a displacement 
without any other anatomical change. There is, therefore, no ob- 
struction, inflammation, or even congestion present, and no symp- 
toms. This form of invagination might ordinarily be reduced by 
the normal peristaltic and vermicular movements of the intestine. 

Invagination of a portion of the small intestine into the part im- 
mediately below it is often observed at the post-mortem examina- 
tion of young infants, who had presented no symptoms due to the 
displacement. The invaginated mass is usually from half an inch 
to two inches in length, and, as a rule, this accident is multiple. 



INTUSSUSCEPTION WITH SYMPTOMS. 653 

There may be tea or more distinct intussusceptions, at distances 
of a few inches from each other. This simple displacement is 
believed to occur ordinarily at or a short time prior to the moment 
of dissolution. It has been supposed to be most frequent in those 
who have died of cerebral or spasmodic diseases, but its occurrence 
is not unusual in other pathological states. I have often found it 
at the post-mortem examination of infants who have had subacute 
or chronic entero-colitis. Hevin states that he has seen it at the 
Salpetriere over three hundred times. Billard has seen it espe- 
cially in infants who have been subject to constipation. Any irri- 
tant, mechanical or other, which disturbs the regular movements 
of the intestines, doubtless may produce it. We learn, from good 
authority, that it can be caused in the rabbit by irritating the 
anus. It is, therefore, probable that the thread as well as round 
worm, by the irritation mechanically produced, may be a cause. 

It is not improbable that simple intussusception occasionally 
occurs temporarily in children whose health remains good, when 
the regular movements of their intestines are disturbed by irri- 
tating ingesta or other causes. This form of displacement never 
takes place in the large intestine. Its usual seat is the lower part 
of the jejunum, and upper part of the ileum. As it possesses little 
interest as regards pathology, and none whatever as regards symp- 
tomatology and therapeutics, it may be ignored in our description 
of intussusception. 

Intussusception with Symptoms. 

Intussusception, or invagination, is one of the most painful and 
dangerous of human maladies, but fortunately not of frequent 
occurrence. I possess the records of fifty-two cases, which are 
tabulated in the Appendix (F) ; and from which the principal facts 
contained in this paper are derived. The patients were under the 
age of twelve years. The statistics furnished by these records, 
therefore, relate to both the periods of infancy and childhood. 

Previous Health.— In thirty-four of the fifty-two cases, the 
state of the health previously to the invagination was recorded. 
From the following table it is seen that half, or seventeen, were 
previously well, the remaining half suffering from some disease or 
derangement : — 

Previous Health. 
A ge. Good. Disease or Derangement. 

One year or under 15 8 

Over one year ...... 2 9 

17 17 



654: INTUSSUSCEPTION. 

MM. Billiet and Barthez, whose views in reference to intussus- 
ception are derived from the examination of the records of twenty- 
five cases, state that the previous health is ordinarily good, and 
the disease is, therefore, primitive. Their remark, according to 
the above statistics, is seen to be correct as regards patients under 
the age of one year, but incorrect for those over that age. 

Most of the seventeen who had previous ill-health had diarrhoea, 
dysentery, or constipation, or diarrhoea alternating with constipa- 
tion. Of those otherwise affected, one had threadworms, two 
obscure abdominal pains, one nausea and vomiting, and one four 
months old had symptoms of invagination, at the age of ten weeks, 
which soon passed off. It is seen that the pre-existing affections 
were ordinarily such as would be likely to accelerate the move- 
ments of the intestines and at the same time render them irregular. 
Causes. — The above statistics, therefore, show that in a pretty 
large proportion of cases of intussusception, there is previous dis- 
ease of the intestine or derangement of its function. This, doubt- 
less, is a cause of the displacement in at least a certain proportion 
of cases. It is proper to attribute a causative relation to the diar- 
rhoeal maladies and constipation, inasmuch as they have been 
found to precede the displacement in so many instances. From 
the records, it is probable that invagination with symptoms, as 
well as the simple form, as already stated, may be caused by the 
irritation of intestinal worms. They were present in three of the 
fifty-two patients, though two of these seemed perfectly well till 
the occurrence of the intussusception. The other patient, imme- 
diately prior to it, complained of soreness around the anus, and 
ascarides were found on examination. 

The use of irritating and indigestible food is regarded by writers 
as an occasional cause. Thus, some who have had intussusception 
have been in the habit of taking fruits, candies, and pastries freely. 
Such ingesta may be an immediate cause by their irritating effect, 
or a remote cause giving rise to diarrhoea, which, in turn, produces 
intussusception. 

Rilliet and Barthez consider the sex a predisposing cause. 
There are more male than female children affected with intussus- 
ception. Of the twenty -five cases collated by them, all but three 
were boys. In our own collection, the sex of thirty-four of the 
patients was recorded, and of these twenty-three were boys. 

In rare cases external violence is the only apparent exciting 
cause. One patient (No. 37, Appendix) received a severe contusion 
of the abdomen two years before death, and from this time con- 



INTUSSUSCEPTION WITH SYMPTOMS. 655 

tinned to complain at intervals of pain in the bowels. One writer 
also mentions the case of a child nine years old who received a 
blow from a comrade at school, and from this time had alternately 
diarrhoea and constipation till the invagination commenced. 
Billiet and Barthez also relate the case of two children who were 
taken suddenly with invagination when their parents were tossing 
them in their arms. 

Age. — Of the fifty-two cases embraced in onr statistics, the ages 
were as follows: — 



3 were 3 months old. 


1 was 10 months old. 


12 " 4 


t( 


(C 


1 " 11 " 


3 " 5 


u 


It 


1 " 12 " 


5 " 6 


u 


it 


2 were from 1 to 2 years old. 


1 was 7 


It 


u 


8 " " 2 " 5 " " 


1 " 8 


IC 


u 


8 " " 2 "5 " " 


3 were 9 


11 


" 


3 not given. 



There were, therefore, no cases under the age of three months, 
23 cases between the ages of three and six months, or nearly one- 
half of the entire number, 8 from the age of six months to one 
year, and only 18 between the ages of one year and twelve. These 
statistics correspond, in the main, with those of Billiet and Bar- 
thez, in whose collection of 25 cases there was no one under the 
age of four months. 

The great liability to intussusception in infancy is due partly to. 
the anatomical character of the intestine in this period of life, and 
partly, doubtless, to the fact that there are more frequent irregu- 
larities in the intestinal movements than in older children. In 
the infant the walls of the intestines are thin, the mucous and 
muscular coats and the connective tissue being much less developed 
than in those that are older ; the mesentery and meso-colon have 
also greater depth as compared with the same in other periods of 
life, except the meso-colon at the points where it passes over the 
kidneys, in which places it is very short, or even in some cases 
nearly absent. Moreover, the space occupied by the large intes- 
tine, in which part of the digestive tube intussusception commonly 
occurs, is much shorter relatively to the length of the intestine 
than in those that are older. In about thirty measurements, which 
I have made of the length of the large intestine and the space 
occupied by it, the latter was found, in the average, about one- 
third that of the former, which, of course, necessitates doubling 
of the intestine on itself. These peculiarities of structure in the 
infant obviously favor the occurrence of intussusception. 



656 INTUSSUSCEPTION. 

Seat and Pathological Anatomy. — While the simple or reduci- 
ble variety of intussusception is usually multiple, the irreducible 
form is ordinarily single. Two exceptional cases will be presently 
related. In one case in our table there was a reducible in addition 
to the irreducible invagination. 

While the simple variety is seated in the small intestine, the 
seat of the irreducible form is, with occasional exceptions, the 
colon. The colon constitutes the entire invaginated mass, or else, 
and more frequently, it forms the exterior, while the incarcerated 
portion consists wholly or in part of the ileum. 

Intussusception in the Small Intestines. 

Bouchut says: "M. Rilliet states, in a recent treatise, that in 
infancy the intestinal invagination is always accomplished at the 
expense of the large intestine, and that there is never invagina- 
tion of the small intestine. This is incorrect. I have observed 
the small intestine invaginated in the adjacent inferior part. Taylor 
has reported a case of this kind in a child twenty months old, who 
died after an attack of acute peritonitis. M. Marage has seen 
another case in a child thirteen months old, who recovered after 
having voided the invaginated portion furnished with two of those 
diverticula so frequent in the small intestine of the foetus." 

But from all that appears, the case reported by M. Marage may 
have been, and probably was, an example of the common form of 
intussusception, namely, of the ileum into the colon. I am not 
certain what case observed by Mr. Taylor is alluded to, but if it 
is No. 18 of our table, as is probable, we see that the invagination 
was really of the ileum into the colon, although a small portion of 
the ileum next to the valve had not been inverted, and constituted 
a little of the exterior of the mass. 

Intussusception, irreducible and fatal, may, however, occur in 
the small intestines in infancy as well as childhood. Probably 
the displacement is at first of the simple variety, but, continuing 
and increasing in extent, its return becomes impossible. The posi- 
tive statement of so great an authority as M. Rilliet, that irredu- 
cible intussusception does not occur in the small intestines, justifies 
the publication of the following cases, which establish the fact 
that there are instances, though not frequent, in which the disease 
does have this location. 

Case 1. — Male. This patient's health had been uniformly good, and 
nothing unusual was observed in his condition till the age of four and 
a half months, when he became restless as if in almost constant pain, 



INTUSSUSCEPTION IN THE SMALL INTESTINES. 657 

with occasional exacerbations. Castor oil was prescribed, which ope- 
rated freely, and then the following mixture: — 

R. Magnes. calcinat. J}j ; 

Tinct. opii camphorat. 31J ; 
Tinct. assafoet. £ss ; 
Aq. anisi 5J. Misce. 
Dose, ten to twenty drops, repeated according to the pain. 

These remedies failed to give relief, as did also chloroform given 
in doses of two drops. After two or three daj^s, another set of symp- 
toms arose, those characteristic of pneumonitis, namely, hurried respi- 
ration, accelerated pulse, short, suppressed cough, and expiratory moan. 
He was treated with the oiled-silk jacket, and mild counter-irritation, 
and took an expectorant mixture containing carbonate of ammonia. In 
a few daj T s the pulmonary disease was evidently subsiding, but the pain 
in the abdomen, with occasional exacerbations, continued. His counte- 
nance was pallid, and bore an expression of suffering. There was no 
distension or tenderness of abdomen, and no abdominal tumor. He 
took little nutriment, and seldom vomited. In the last part of his sick- 
ness the dejections were scantj^, and the last three days his stools con- 
sisted mainly of mucus and a little blood. The pain seemed to be grow- 
ing less, when he was seized with convulsions, and died the same day, 
precisely two weeks from the commencement pf his sickness. 

Sectio Cadaver. — Head not examined; body slightly emaciated; 
mucous membrane of trachea and bronchial tubes vascular ; posterior 
portion of the lower lobe of each lung solid, of a greater specific gravity 
than water, and allowing only partial inflation ; it was in the second 
stage of pneumonitis. Stomach, duodenum, jejunum, healthy. In the 
upper part of the ileum was an intussusception two-thirds of an inch 
long, presenting no trace of inflammation, either within or around it, 
and its vascularity, when it was examined externally, did not seem 
notably increased. Above the intussusception the intestine was empty ; 
below it, and chiefly in the small intestine, was a dark-colored substance 
evidently blood, and giving in a few hours the offensive odor of decaying 
animal matter. There was a passage through the intussusception, at 
least two or three lines in diameter, as shown by a probe. The intussus- 
ception sustained the weight of sixteen inches of the intestine, and it 
would apparently have sustained considerably more. The remaining 
organs were healthy. 

Case II. — F. S., a female infant, four months old, was treated at the 
New York Infant Asylum in June and Julj T , 1865, for entero-colitis, the 
usual epidemic of the summer season. The following records show the 
state of the bowels immediately before her death : — 

June 29th. Has five or six stools daily. 30th. Two stools in twenty- 
four hours. July 1st. Had two stools since the last record ; no vomit- 
ing. 3d. Four dejections in twenty-four hours. 4th. The diarrhoaa 
continues as before ; dejections about four daily. On the 6th of July 
she died. 

Her pulse during the time in which these records were taken gene- 
rally numbered about 128 per minute. She was much emaciated, and 
the day before death she frequently struck her head with the hand. 
The medicines employed were mainly alkalies and astringents. 

Sectio Cadaver. — Parietal bones united ; serous effusion lying over 
the convolutions of the brain, under the arachnoid ; occipital bone 
42 



658 



INTUSSUSCEPTION. 



depressed ; commencing at a point about two feet below the stomach 
were four intussusceptions two or three inches from each other. The 
invaginated masses were from one to one and a half inch in length, and 
three of them were found to be very vascular in their interior. Above, 




between, and immediately below the intussusceptions the intestine was 
healthy. One of the invaginations was tested by weight, and was found 
to sustain one and a half foot of intestine, and would have sustained 
more. Water poured above these intussusceptions escaped through 
them very slowly ; no fibrinous exudation ; descending colon vascular 
and thickened, and solitary glands enlarged. 

The irreducible character of the intussusceptions in the above 
cases was shown by the fact that they sustained weights which 
doubtless produced greater traction than that exerted by the in- 
testine in its normal action. That the displacement existed prior 
to the moment of death was shown not only by the symptoms in 
one case, but by the anatomical changes which had occurred in 
both. In one the capillaries of the incarcerated mass were rup- 
tured during the last days of life, so as to produce sanguineous 
stools ; while in the other there was intense congestion of the 
confined membrane, while that adjacent was healthy. 

In both cases there was less violence of symptoms, and the 
disease seemed to come on more gradually than in the first and 
second cases of our table, in which the portion of intestine which 
was engaged was the same, but the patients older. In fact, the 
imprisoned intestine was pervious, so as to allow the passage of 
food in one case through the entire sickness, and in the other till 
near the close of life. At the post-mortem examinations, the 



INTUSSUSCEPTION" IN" LARGE INTESTINES. 659 

intestines were found empty above the intussusceptions, and water 
slowly passed through them. 

It is my opinion that intussusception of the small intestines in 
the infant, commencing as the simple form, may become irredu- 
cible, and yet remaining pervious continue for weeks without 
giving rise to those severe symptoms which ordinarily characterize 
this disease. The following case, which I have not thought best 
to include in my table, was apparently an example of this : — 

Case. — Male child, died at the age of nineteen months, the last eleven 
of which he was under observation. The mother states that he had 
never been well since the age of one month, and that there had been little 
variation in the symptoms of his disease. During the period in which 
he was under observation, he was ordinarily fretful, and frequently 
seemed to be in considerable pain. His stomach through this whole 
time was so irritable, that he rarely took more than three or four spoon- 
fuls of nutriment without vomiting. There was usually more or less 
diarrhoea, but no tenderness or distension of abdomen. He became 
slowly but gradually more emaciated, and finally died in a state of 
extreme emaciation and exhaustion. He had no convulsions, and was 
conscious to the last. 

Sectio Cadaver. — Brain not examined; lungs healthy, except a cir- 
cumscribed portion, which was inflamed at the summit of the right lung; 
liver small and almost destitute of oily matter, as shown by the micro- 
scope. In the jejunum, about two feet below the stomach, was an intus- 
susception two inches long, the intestine forming which seemed to have 
undergone no structural change. Above the intussusception the intestine 
was of small calibre, and entirely empty and pale ; below the intussus- 
ception the intestine was somewhat larger than above, but it seemed 
quite healthy. The invagination was sufficiently pervious to allow water 
to pass through it, and it readily sustained the weight of two feet of 
intestine. From eight to ten inches below this intussusception there 
was another, which was immediately drawn out the moment the intestine 
was disturbed. The other abdominal viscera were healthy. 

There is uncertainty as to the duration of intussusception in the 
above case. Though the symptoms indicated that it existed a 
considerable time prior to death, yet there was no strangulation, 
nor indeed any appreciable anatomical alteration in the coats of 
the intestine. The fact that the invaginated mass sustained two 
feet of intestine, and required considerable traction for its reduc- 
tion, transfers the case from the simple to the irreducible variety. 

Intussusception in Large Intestines. 

In most cases of irreducible intussusception in infancy and 
childhood, the ileum is invaginated in the colon, or the first part 
of the colon is invaginated in the part succeeding it. By referring 
to the table (Appendix) it will be seen that intussusception not 
unfrequently begins in the prolapse of the ileum through the ileo- 



660 INTUSSUSCEPTION. 

coecal valve, in the same way that prolapse of the rectum occurs 
through the sphincter ani. If death take place early, as in Case 6, 
only a small portion of the ileum may have passed the valve. If 
the case is protracted, the tenesmus brings down more and more 
of the ileum, with its accompanying mesentery. The constriction 
of the valve, which acts as a ligature, soon prevents the further 
descent of the ileum; and, the tenesmus continuing, the next step 
in the morbid process is the inversion of the caput coli, which is 
drawn into the colon by the descending mass, and, unless the case 
terminate by sloughing or death, the ascending and transverse 
portions of the colon are successively invaginated. The records 
show that intussusception occurs as above stated in a large pro- 
portion of cases. In one case, No. 18, the intussusception began 
a few inches above the valve, so that the ileum constituted a small 
portion of the exterior of the mass. Occasionally the ccecum is 
the part primarily inverted and invaginated, and, descending along 
the colon, it draws after it the ileum, which sustains its natural 
relation to the ileo-ccecal valve. "When this occurs the ccecum is 
found at the lower end of the mass, and two orifices are observed, 
one leading through the valve, and the other into the appendix 
vermiformis. In Cases 14, 17, 20, 21, 26, and 37 (Appendix), the 
intussusception evidently commenced with the caput coli. These 
two forms of invagination — that in which the ileum, passing 
through the ileo-ccecal valve, successively inverts and draws after 
it the caput coli and the divisions of the colon ; and that in which 
the caput coli is primarily invaginated, and descending along the 
large intestines, inverts the latter, and draws after it the ileum — 
constitute the vast majority of cases of this disease in infancy and 
childhood. In Cases 5 to 42, the parts invaginated were the ileum 
or caput coli, or both, generally with a portion of the colon. In 
one case, 44, the intussusception was in the transverse colon ; in 
one, 43, in the descending portion; and in one, 45, in the lower 
portion of the descending colon and in the rectum. Earely (24, 
35, and 37) double invagination occurs. The first invagination 
becomes arrested in its progress, and by the strong expulsive effort 
of the patient, descends into the portion of intestine below, form- 
ing a mass of great thickness, and necessarily fatal. In exceptional 
cases there is so little constriction of the invaginated intestine that 
it remains pervious, though with diminished calibre. In these 
cases life may be protracted for weeks or even months, the evacu- 
ations being sufficient for the wants of the system. Death occurs, 
finally, in a state of exhaustion. Case 9 was a notable example of 



INTUSSUSCEPTION IN LARGE INTESTINES. 661 

this. This child, four months old, lived six weeks after the 
symptoms of invagination commenced, and seventeen days "with a 
portion of the bowel protruding from the anus." It was found at 
the post-mortem examination that part of the ileum had descended 
through the entire colon, and had remained pervious. Case 37 
was another example of the same. It is not known at what time 
the invagination began in this case, though there were symptoms 
of it for seven months before death. During the last six weeks of 
life, the invaginated intestine protruded frequently from the anus, 
and was replaced by the mother. In this case " the ccecum was 
inverted, and descended through the colon to the lower portion of 
the rectum, carrying with it the ileum and the entire colon, except 
the last ten or twelve inches.'"' In Case 21 the symptoms indicated 
a continuance of the disease for three, if not eight, months. As the 
intestine becomes invaginated, its mesentery or meso-colon is also 
invaginated, and, with rare exceptions, its veins compressed. The 
pathological state of the incarcerated mass soon becomes that of 
intense congestion. In infants, usually in a few hours, so great is 
the distension of the capillaries that they give way, blood escapes 
into the intestine, and passes from the bowels in scanty motions. 
On examining the invaginated intestine after death, if gangrene 
has not occurred, it is found of a uniform intense red color, some- 
times resembling to the naked eye a long and firm clot of blood. 
In those who die early there are no traces of inflammation, but in 
more protracted cases the attrition between the serous surfaces 
excites local peritonitis. In none of the fifty-two cases in which 
post-mortem examinations were made, did the inflammation extend 
more than a few lines beyond the invagination. Usually the 
intestine forming the exterior of the invaginated mass is much 
drawn together or puckered. In the case treated by myself, 36, 
the entire large intestine which formed the exterior was compressed 
within a space of six inches or less, since about twelve inches of 
the ileum doubled on itself, passed through the entire colon so as 
to protrude from the anus, the only part of the large intestine 
inverted being the caput coli. In Case 18, six or seven inches of 
the ileum, which formed a portion of the exterior of the mass, were 
compressed within the space of one inch. 

The abdomen, at first of natural fulness and soft, usually becomes 
more and more distended till the close of life ; but in cases of much 
vomiting the distension is moderate. This fulness is due to gas 
and faecal accumulation above the invagination. The portion of 



662 INTUSSUSCEPTION. 

intestine below it is generally empty, unless it contain a little 
blood, and is sometimes contracted. 

There are few morbid changes in intussusception beside those 
pertaining to the intestine. Sir James Y. Simpson saw Case 51, 
and remarked, before the medical society at which the specimen 
was exhibited, that it appeared to him, from the distended state of 
the cutaneous veins, that the ascending vena cava was compressed 
by cicatrization at the point where the intestine had sloughed. In 
Case 40, there was probably compression of the left iliac artery; 
for two days after the expulsion of the ccecum and a part of the 
colon which had sloughed, pulsation ceased in the left leg, and all 
that part below the patella became gangrenous. The patient 
gradually recovered with the loss of the leg. The only probable 
explanation of such cases is that the bloodvessels are compressed 
by the cicatrization and contraction which follow the sloughing 
of the intestine, such as occurred in Case 48. This child, on the 
eighth day of his sickness, lost by stool fifteen to eighteen inches 
of the ileum, after which he rapidly recovered. Twelve weeks 
later he was seized with typhus fever, which proved fatal in two 
weeks. The records state, a The traces of the diseased bowels 
were visible by a considerable puckering and contraction where the 
slough had taken place and the parts united." This case shows 
that the supposition that cicatrization in rare instances arrests the 
circulation and gives rise to gangrene receives confirmation from 
post-mortem inspection. In Case 40, although the ccecum and a 
part of the colon contiguous were discharged, the seat of the 
invagination was probably the descending colon, if not lower still, 
so as to correspond with the common or perhaps internal iliac 
artery. 

Symptoms. — The symptoms vary according to the age of the 
patient and the degree of strangulation in the part invaginated. 
Pain in the abdomen, usually paroxysmal, is among the first, and 
is one of the most conspicuous symptoms. It is often severe, 
resembling the pain of hernia, and abating only with the failing 
strength of the child. After the first few days, if inflammation 
arises, the pain is continuous, though more severe in paroxysms. 
At first pressure upon the abdomen is tolerated, but afterwards 
there is tenderness. This is also due to the inflammation, which 
occurs in and around the invaginated mass. It is therefore con- 
fined to the part of the abdomen which corresponds with the 
invagination. At this point the abdomen is more full than else- 
where, and not unfrequently the physician can feel the invaginated 



SYMPTOMS. 663 

mass and detect its exact location. Sometimes, at an early period 
as well as late, cerebral symptoms occur, as in Case 6, which termi- 
nated in convulsions on the second day. Convulsions are, however, 
comparatively rare, and the mind is generally clear till the last 
moment. In infants the countenance, in the intervals of pain, in 
the first stages of the complaint, is often placid and not indicative 
of any serious disease, but in older patients constant and severe 
local symptoms, referable to the intussusception, commence early. 
At an advanced period, whatever the age, the countenance becomes 
anxious and haggard, the eyes hollow or sunken, the body loses its 
plumpness, and, if the case is protracted, becomes emaciated. 

Vomiting is rarely absent ; in thirty-nine out of forty-seven 
cases it is stated to have been present ; in seven cases there is no 
record of this symptom, while it is recorded absent in only one 
case. This is Case 52, the record of which is very meagre, and 
death occurred the second day. The vomiting becomes stercora- 
ceous in a few days, and it ordinarily continues with greater or 
less frequency till the period of collapse. It relieves partially the 
distension. 

The appetite is impaired and often entirely lost. Infants at the 
breast commonly nurse, however, for several days, probably from 
thirst rather than hunger. 

There is commonly one natural evacuation from the bowels after 
the intussusception commences, and then obstinate constipation 
succeeds. This evacuation consists of the excrernentitious matter 
below the invagination. In children under the age of one year, 
scanty motions of blood mixed with mucus begin to occur in a few 
hours. In twenty-seven children under this age I find that twenty- 
four had such evacuations, occurring in most of them several times 
in the course of the day ; in two of the twenty-seven there is no 
record of this symptom, but in the remaining case it is stated to 
have been absent. Scanty evacuations of blood unmixed with faecal 
matter have been considered pathognomonic of intussusception in 
the infant, and we see the ground for such belief ; but in excep- 
tional instances the invaginated mass is partly pervious, and al- 
though the dejections may contain blood they are also excrernen- 
titious. In our collection of cases are three examples of this in 
infants under the age of one year. One has already been referred 
to. In this case there was the rare anomaly of so large an opening 
through the ileo-coecal valve, as to allow not only prolapse and de- 
scent of the ileum through the entire colon, so as to protrude six 
inches from the anus, but also faecal passages through it daily. 



664: INTUSSUSCEPTION. 

In children above the age of one year, the capillaries of the 
invaginated intestine are not so frequently ruptured as under this 
age, and sanguineous evacuations are therefore less common. I 
have records of nineteen cases between the ages of one year and 
twelve, in only six of which is it stated that there were bloody 
motions, and in these the blood was not passed frequently, nor even 
in some cases daily, as in infants, nor in so pure a state, unless in 
Cases 9 and 11, the records of which are not explicit on this point. 
Two of these six patients passed moderate bloody evacuations after 
protracted periods of constipation, one had faecal discharges with 
the blood through the entire sickness, and in one blood was passed 
at first but finally the stools were entirely excrementitious. 

In those above the age of one year, there was for the most part 
obstinate constipation, no dejections, whether bloody or faecal, 
occurring for several days, but there were a few exceptions. In 
Cases 7, 21, and 37, the bowels were relaxed. The ileum, in these 
three cases, had descended through the entire colon, or the larger 
part of the colon, and being pervious, the faeces escaped from the anus 
without detention in the large intestine, or with detention only in 
its lower portions, and were therefore liquid. 

Tenesmus is another symptom. It is not always present, but 
in a large proportion of cases, even when the invagination is in 
the upper part of the large intestine, it is a frequent and distress- 
ing symptom. It often does not commence till there is a consider- 
able amount of displacement, and it ceases when the strength is 
much reduced. 

The temperature of the surface is normal in the commencement 
of intussusception ; but finally, as febrile reaction comes on symp- 
tomatic of the inflammation, it rises and continues above the 
healthy standard till the intestine sloughs, or till the stage of 
collapse occurs which ushers in death. The pulse, especially in 
the infant, is tranquil at first, but, whatever the age, it soon 
becomes accelerated from the paroxysms of pain, and subsequently 
from the inflammation which occurs in the invaginated mass. 
There is no disturbance of respiration, except that it is somewhat 
hurried from the fever, and from the pain felt in advanced cases on 
full inspiration. 

It will be seen that the symptoms vary in certain particulars, 
under the age of one year, from those occurring over that age, but 
differences in the symptoms depend more on the degree of invagi- 
nation and constriction, than on the age and exact location of the 
disease. 



DIAGNOSIS — DURATION. 665 

Diagnosis. — The diagnosis of intussusception is not, in general, 
difficult, except at its commencement. "When the inversion has 
reached that degree at which obstruction occurs, the symptoms 
are, in most" cases, such that the disease can be readily diagnosti- 
cated. In the cases the records of which I have collected, a 
correct diagnosis was, with few exceptions, made, and at an early 
period. In the infant, the disease for which intussusception is 
most frequently mistaken is dysentery, on account of the tenesmus 
and the muco-sanguineous stools. In certain of the reported cases 
this mistake was not rectified until it was ascertained that purga- 
tives produced no faecal evacuations. 

The symptoms which are commonly present, and which indicate 
the nature of the disease, are obstinate constipation, vomiting, 
paroxysmal pain referred to the seat of the disease, and tenesmus. 
In the infant, also, scanty evacuations from the bowels of mucus 
and blood, or of pure blood, is an important diagnostic sign. It 
should, be borne in mind, however, that in exceptional cases the 
displaced bowel may remain pervious, and the symptoms which 
possess so great diagnostic value therefore be absent. There may 
be no vomiting or tenesmus, and there may even be diarrhoea in 
place of constipation. As an aid to diagnosis, it should be stated 
that whatever the age of the child affected with intussusception, 
clysters are commonly administered with difficulty, and are quickly 
and forcibly returned, on account of the resistance opposed by the' 
invaginated mass. The seat and even extent of displacement can 
be ascertained in a large proportion of cases by a digital examina- 
tion of the abdominal walls. The tumor can be felt hard, elongated, 
and tender on pressure. If the invagination be in the lower part 
of the large intestine, it can sometimes be discovered by an exami- 
nation per rectum. 

Duration. — In the following table, the duration of the intus- 
susception in forty-nine cases is given, as nearly as it can be 
ascertained from the records: — 

1 died the 8tli day. 
1 " "10th '* 
1 " "14th " 
1 lived nearly a week. 
1 " (Case 9) 6 weeks. 
3, time of death not given. 
7 recovered. 
1 lived over a week. 

In the three remaining cases, 4, 21, and 37, the exact duration 
is not certain ; but it was probably far beyond the usual period. 



2 died the 1st day, 


6 " 


" 2d " 


14 " 


" 3d " 


2 " 


" 4th " 


5 " 


" 5th " 


2 " 


" 6th " 


2 " 


" 7th " 



6$6 INTUSSUSCEPTION. 

The second of these (21), a girl of six years, having eaten raw 
carrots, was seized with pain in the abdomen, which lasted eight 
months, when she died. During the last three months she passed 
mucus and blood. In this case the coecum had descended to the 
anus, drawing with it the ileum, which remained pervious. The 
symptoms indicated the continuance of the invagination for three 
months if not eight. In the third case (37), the child complained 
of pain in the abdomen for many months, and occasionally vomited. 
During the last six weeks of his life, all the phenomena of invagi- 
nation were present. The pathological condition of the intestine 
found after death was essentially the same in both cases. 

In West's Treatise on Diseases of Children (fifth edition, 1866, 
page 504), it is stated that death in this complaint always occurs 
within a week. The above statistics, however, show that there 
are exceptions to this statement, although a large majority do die 
within the first seven days. In thirty -three of the cases embraced 
in my statistics death occurred within the first week, and in no 
fatal case in which strangulation was complete was life prolonged 
beyond the eighth day. In these cases of complete strangulation 
the average duration was 3.7 days, and the largest number of 
deaths occurred on the third day. Death on the first day is rare, 
but it occurred in two instances. When so early it is often, if not 
generally, through convulsions and coma. 

Prognosis. — Intussusception is in its nature so grave an accident 
that the physician called to a case should always expect and pre- 
dict a fatal result. A favorable issue is only through an unusual 
combination of circumstances. But, while death is the common 
result, there are three different modes of termination in which life 
is preserved. First, the reduction of the incarcerated intestine, 
with immediate relief. There can be no doubt that it is possible 
for intussusception, when recent, to be reduced by the unaided 
action of the bowels, in the same way as the common, simple in- 
tussusception in the jejunum and ileum, or. as hernia is reduced, 
through the vermicular action of the intestines. For sometimes, 
as in Case 6, there previously have been the same symptoms as 
those which accompanied the fatal attack, and which subsiding, 
the patient remained for a time in perfect health. This termina- 
tion is probably rare, if the symptoms are sufficiently marked to 
necessitate treatment. A considerable number of observations 
also establish the fact that intussusception may occasionally be 
cured by early and well-applied treatment. The physician may 
succeed in reducing the displaced intestine, even if the intussus- 



PROGNOSIS. 667 

ception is in the upper part of the colon. Eelief in these cases, 
whether by the unaided movements of the intestine or by the phy- 
sician's art, is obviously immediate. 

A second mode of favorable termination is alluded to by certain 
foreign writers. The intussusception continues for a considerable 
period with the characteristic symptoms, and then, as Bouchut 
expresses it, " the vomitings gradually cease, the intestinal hemor- 
rhage disappears, the strength returns, and the health becomes 
restored without the expulsion of fragments of the intestine." 
What changes the displaced intestine undergoes in these protracted 
cases, which gradually recover without sloughing, have not been 
clearly ascertained, although they have been the subject of con- 
jecture. According to Billiet, a large proportion of favorable cases • 
terminate in this manner. It does not appear, however, from the 
statistics which I have collected, that this is a common mode of 
recovery. The clinical history of intussusception establishes the 
fact that in a large majority of protracted cases there is either death, 
or the third mode of favorable termination, namely, by sloughing. 

Infants with intussusception other than the simple form, which 
was described at the beginning of this paper, commonly die. The 
reason of this is obvious when we consider that, in a few hours after 
the invagination begins, the imprisoned mass, with now and then 
an exception, becomes so congested that its capillaries give way, 
and its reduction is impossible by any appliance of medical art. 
We cannot reasonably expect recovery except through sloughing 
and the expulsion of the intestine ; and few infants have the re- 
quisite strength for so tedious and exhaustive a process. The 
youngest child that recovered in this way, so far as I can ascertain, 
was one reported by M. Marage, namely, an infant thirteen months 
old. With the exception of this case, the youngest was (42) a boy, 
five years of age. The older the child, the greater, of course, the 
power of endurance, and the better the prospect of recovery. In 
our collection are the records of seven cases which resulted favor- 
ably by sloughing. These children were of the ages of five, six, six, 
nine, eleven, twelve, and twelve years. The separation of the 
invaginated mass occurred in six of these between the sixth and 
twelfth days, with an average of nine and a half days, the time not 
being given in one case. If, then, the patient can be carried 
through the first week without too much exhaustion, we may each 
day look for the discharge of the slough, the reopening of the bowels, 
and ultimate recovery. 

In those rare cases in which there are daily faecal dejections, 






INTUSSUSCEPTION. 

recovery is still improbable. At an early period reduction is no 
doubt more easy in these cases than when there is strangulation, 
but from the absence of strangulation the intussusception usually 
becomes greater, and sloughing is less likely to occur; so that, 
although the case is more protracted and the symptoms less severe, 
death is the ordinary result. 

Mode of Death. — In a large majority of cases death is through 
asthenia. There may be convulsive movements, more or less 
marked, but the prevailing characteristic as death approaches is 
extreme exhaustion. In exceptional cases the life of the sufferer 
is cut short by convulsions before the stage of exhaustion is reached, 
as in Cases 2 and 6. 

Treatment. — It is unfortunate, in cases of intussusception, that 
the time in which treatment can be of most service is apt to pass 
by, before the true condition of the intestine is detected. Invagi- 
nation being comparatively rare, the patient is generally on the 
first day treated for colic or dysentery or some other common affec- 
tion of the bowels ; and it is often not till the second day, when 
the intestine has become incarcerated, that the physician accu- 
rately diagnosticates the disease. The purgative medicines usually 
given in the commencement injure the patient. In fact, both 
reason and experience teach us the impropriety of such treatment 
in this complaint. Cathartic remedies act as a vis & tergo, and may 
cause a still further descent of the inverted intestine. Yet such 
powerful agents of this class as quicksilver have been employed. 
It was administered in two doses of one ounce each in one of the 
cases embraced in my statistics, but none of the mineral passed the 
bowels. At the post-mortem examination a considerable part of 
it was found in small globules, coated with a black layer consist- 
ing of the sulphuret or black oxide of mercury in the intestine 
above the intussusception. It need not be added that the case was 
speedily fatal. 

The proper treatment of intussusception consists in attempts to 
reduce the displacement by pressure from below. This pressure 
may be applied either by liquid injections into the rectum, or, 
which is far preferable, inflation of the lower intestine by air or 
gas. If reduction is not effected after sufficient trial, the indica- 
tion is to sustain the strength of the patient and give palliative 
remedies in the hope that recovery may take place through the 
process of sloughing and adhesive inflammation. If we may judge 
from the remarks of physicians who have reported cases, and by 
discussions in societies in which specimens have been presented, 



TREATMENT. 669 

this mode of treatment is accepted by the profession generally, and 
the medical journals contain many reports of cases successfully 
treated in this manner. Inflation as compared with liquid injec- 
tions produces a more equable and effective distension of the 
external or incarcerating portion of intestine, and cases of cure 
by inflation have been reported after injections had failed. Treat- 
ment by inflation, which indeed ought to occur to any intelligent 
physician, appreciating the anatomical condition of the parts, as 
the correct mode, was prominently brought to the notice of the 
profession in modern times by Mr. Samuel Mitchell, in a commu- 
nication to the London Lancet for March 17th, 1838. 

U I take the liberty," he writes, " of suggesting to the profession, 
through the medium of your valuable periodical, the trial of 
inflating the bowels by means of a glyster-pipe attached to a 
common pair of bellows ; it has fallen to my lot to witness several 
of these most distressing cases in children; the nature of the 
obstruction was foretold during life, and unfortunately verified by 
post-mortem examination. The last case of the kind which came 
under my care, about two years since, presented all the usual 
symptoms: intolerable restlessness, the most obstinate sickness, 
the singularly distressed state of countenance, and shrunken 
features. The usual remedies were had recourse to, viz., warm 
baths, glysters, anodyne frictions over the abdomen, etc., but 
without avail. As a forlorn hope I made trial of inflation by the 
above means, with the most happy result. The sickness immedi- 
ately ceased; the child within an hour passed a natural stool, and 
in the morning was almost without ailment." 

This mode of treatment is termed novel in the Lancet , but it is 
really as old as the time of Hippocrates, who speaks of throwing 
air into the bowels, by which flatulence is imitated (flatus immi- 
tatur). (Hippocrates' Works, translated from the Greek by Grimm, 
4 bd., page 198.) Haller also recommended the same treatment : 
"Flatus etiam immissus celerime susceptionem dispellet." (Physi- 
ologia Corporis Humani, torn. vii. p. 95.) In the Edinburgh Medical 
Journal, October, 1864, Dr. David Greig relates five cases of suc- 
cessful treatment of intussusception by inflation. The first, an 
infant six months old, previously in good health, suddenly became 
very fretful, apparently having severe paroxysmal pain in the 
abdomen. She had vomiting, and finally tenesmus, with bloody 
evacuations. Warm water enemata could not be administered on 
account, the writer thinks, of the spasmodic action of the intestines, 
and an abdominal tumor could be distinctly felt near the umbilicus. 



670 INTUSSUSCEPTION. 

Castor oil and a purgative powder, and enemata of water having 
been employed in vain, and the case becoming really critical on 
the second day, inflation was employed. The writer says: "The 
nozzle of a small pair of bellows was introduced into the anus, 
and air injected to a considerable extent. Contrary to our expec- 
tation, the air passed readily into the bowel, and seemed to give 
the child great relief. After the injection it lay very quiet, as if 
asleep, and evidently quite free from pain. In about twenty 
minutes from the time the air injection was administered a slight 
rumbling noise was heard in the child's abdomen, followed by a 
crack so loud and distinct as to alarm the attendants in the room, 
who thought something had burst in the child's bowels. The 
child, however, continued as if asleep and free from pain, and in 
about half an hour a large feculent stool, slightly mixed with 
blood and mucus, was passed without pain. During the night the 
child rested pretty well, had no return of vomiting, took the 
breast as usual, and in two days was quite well." 

Another child nine months old, treated by Dr. Grreig, presenting 
nearly the same symptoms and the abdominal tumor, also obtained 
relief by inflation, after castor oil and enemata had failed to pro- 
duce any benefit. 

An apparatus for the production and injection of carbonic acid 
gas has been invented by Schultz and "Warker, of this city, and is 
manufactured by them. It consists essentially of two glass 
chambers, one over the other. In the lower one a bicarbonate is 
placed, and in the upper an acid in a liquid state. By the gradual 
admixture of the two, carbonic acid is set free. An elastic tube 
conveys the gas from the lower chamber. This apparatus has 
been used by physicians of the city, for the reduction of intussus- 
ception and other purposes, and is a useful invention. 

The same firm, and several others in this city, prepare for the 
shops quart bottles of highly charged carbonic-acid water, from 
which when inverted a powerful current of carbonic acid gas can 
be obtained. Two or three of these bottles, with a portion of the 
tube from Davidson's syringe, which can be readily attached to the 
stem from which the gas escapes, constitute all that is required for 
an ordinary case. 

The following cases, which I treated with Dr. Buchler, of this 
city, in 1871, show what may be achieved by inflation, and also 
the unfavorable result which must inevitably occur in certain 
cases. A German infant, live months old, nursing, began to be 
fretful, crying often on March 7th, and before night passed a 



TKEATMENT. 671 

scanty motion of blood. The symptoms continuing, I was asked 
to examine the infant on the 10th, and learned the following facts: 
It had vomited daily, had had daily scanty but infrequent stools, 
consisting chiefly of blood, accompanied at first by tenesmus, but 
not within the last day ; it continued to nurse, but was becoming 
thinner and weaker, and was evidently in pain. The symptoms 
indicating the nature of the disease, the abdomen, which was not 
distended, was examined for the tumor, which was found in the 
right side in the site of the ascending colon, apparently about one 
and a half to two inches in length; pulse 124 in sleep; no cough. 
An ineffectual attempt was made to reduce the intussusception by 
a very rude and imperfectly constructed apparatus (the bellows), 
when from the lateness of the hour farther treatment was post- 
poned till early the following morning. 11th. Tumor still detected 
in the right lumbar region ; pulse 120 asleep, 150 awake. By means 
of Schultz and "Warker's apparatus, the intestines were inflated so 
as to produce very decided prominence of the abdomen, and the 
abdomen gently kneaded. After some minutes the gas was 
allowed to escape, when the tumor had disappeared. In a few 
hours, a natural evacuation occurred from the bowels, and the 
infant has remained well since. 

The second case ended unfavorably, although the symptoms 
were apparently no more grave than in the case just related, and 
had continued a shorter time. This infant was also of German 
parentage. The tumor, firm and elongated, could be distinctly felt 
in the left lumbar region. In this case the inverted bottles of 
carbonic-acid water were employed, and when, after considerable 
delay and kneading of the abdomen, the gas was allowed to escape 
from the intestine, the tumor had disappeared. A few hours 
afterwards convulsions occurred ending fatally. At the autopsy 
the invaginated mass, which was too firmly strangulated to admit 
of reduction by inflation, was found in the epigastric region, having 
been carried up from its former position by the inflation of the 
intestine below. It consisted of the terminal part of the ileum, 
which had passed through the ileo-cceeal orifice, and become incar- 
cerated in the ascending colon, and, as is not unusual in these cases, 
the action of the intestines had changed the location of the tumor 
in the abdomen from the right to the left side. 

Whether air or carbonic acid is employed, it is necessary to 
produce distension of the intestine to its fullest extent below the 
seat of the complaint, without endangering rupture, and of course 
the sooner it is used the better the chance of success. In two or 



672 INTUSSUSCEPTION. 

three days the inverted intestine has, in a larger proportion of 
cases, become so firmly incarcerated, and has descended so far, that 
attempts to replace it are unsuccessful ; still, even at a late period, 
a persevering attempt should be made, if it has not been previously 
tried. 

If, in the failure of inflation to reduce the intussusception, injec- 
tions of water are employed, the thighs should be elevated above the 
shoulders in order to obtain the aid of gravitation, but if inflation 
is unsuccessful, probably the less effectual method of injection will 
fail also. The employment of quicksilver by the rectum with the 
thighs elevated has been suggested to me as a dernier ressort. This 
may be a useful suggestion, especially for those cases in which the 
intussusception occurs in the descending colon. 

When the above measures have failed to relieve the patient, it 
has been proposed to cut down upon and replace the intestine, in 
the same way as the surgeon treats strangulated hernia, and this 
operation is said to have been successfully performed in the adult. 
If the tumor can be readily detected by external examination, if 
its position be favorable and the patient an adult, the propriety of 
such an operation might be seriously considered, but I apprehend 
that there are few surgeons at the present day who would perform 
or recommend this mode of treatment in the child. The child, 
and especially the infant, could hardly recover from the shock of 
so severe an operation, even if it escaped peritoneal inflammation. 
As an objection to the use of the knife is the important fact, which 
distinguishes intussusception from hernia, that sloughing, which 
finally occurs if life is prolonged, is conservative in the former, 
though fatal in the latter. After failing to return the intestine by 
the mode described above, active measures should be discontinued, 
and the treatment should be expectant. Eecollecting that death 
is from asthenia, and that after a certain time, if the strength holds 
out, adhesive inflammation occurs, and the mass which closes the 
intestine sloughs and is expelled, we should endeavor to sustain 
the vital powers by nutriment and stimulants, and relieve the pain 
by the judicious use of opiates. At this stage of the complaint 
there is local peritonitis between the coats of the intussusception, 
and this requires the administration of opium in some form. 
Sustaining and expectant measures ought to be adopted at an early 
period. The diet should consist of beef essence or other concen- 
trated nutriment which leaves little residuum. 

Vomiting, which is so constant, requires no treatment. It 



TEEATMENT. 673 

relieves the distension and prevents fsecal accumulation, which, 
pressing downwards, increases the extent of the invagination and 
counteracts the effect of the injections. Convulsions are to be 
treated by the local measures which are appropriate when they 
occur under other circumstances. At first no external treatment is 
required over the seat of the invagination, but, when the abdomen 
becomes tender and painful from the local peritonitis, poultices are 
of service. 



43 



SECTION IY. 

DISEASES OF CIRCULATORY SYSTEM. 



CHAPTER I. 

CYANOSIS. 



Certain of the diseases which pertain to the circulatory system 
have been treated of in other parts of this book (umbilical hemor- 
rhage, gastro-intestinal hemorrhage, etc.). It remains to consider 
that general condition of the blood which is desiginated morbus 
cseruleus or cyanosis. 

In 1863, 1 read before the New York Academy of Medicine a 
statistical paper on cyanosis, which was published in the Trans- 
actions of that Society. This paper contains an analysis of 191 
cases, collated from the various European and American medical 
journals, and to these cases I am indebted for most of the follow- 
ing facts pertaining to this* disease. 

The term cyanosis or blue disease is differently employed by 
writers. Some apply it to cases of transient lividity occurring in 
the course of acute diseases, as well as to those cases which depend 
on permanent structural changes, or on malformations. I apply 
this term, as do most pathologists, only to the latter cases. 

Some are inclined to discard the consideration of cyanosis as a 
disease, regarding it rather as a symptom. Their view is, in my 
opinion, correct in reference to the cyanotic state, which occurs in 
certain acute diseases, but not in reference to cyanosis, as I have 
defined the term and employ it. The propriety of considering cya- 
nosis a disease is more apparent if we are not misled by the term 
which designates it. Lividity is not its most important or its es- 
sential characteristic. It is simply a sign, although conspicuous, 
and, indeed, the only one by which the disease can be readily recog- 
nized. Cyanosis is, in reality, a blood disease, its pathological 
state consisting in a deficient oxygenation of this fluid, or in an 
excess in it of carbonic acid, and probably of carbonaceous products. 



LITERATURE OF CYANOSIS. 675 

It should be placed in the same category with leucocythemia and 
melansemia. 

Statistics show that cyanosis is, with very few exceptions, clue 
to malformation in the circulatory system, and at the centre of 
circulation, namely, in the heart and in the large vessels which 
arise from this organ. In the exceptional cases, the cause of the 
cyanosis is located in the lungs, and is in all or nearly all in- 
stances either extensive emphysema in both lungs, firm and thick 
fibrinous exudation over both lungs, compressing them by its con- 
traction and causing perhaps carnification in parts of them, or the 
cause is compression of the lungs from caries of the vertebrae, and 
consequent depression of the ribs. These causes pertain to youth 
and manhood, rather than to infancy and childhood. On account 
of this fact and the rarity of such cases they need not be considered 
in this connection. 

Literature of Cyanosis. 

The ancient physicians, so far as can be ascertained from their 
writings still extant, were ignorant of cyanosis ; whether they 
overlooked it, or whether those early ages were exempt from it, 
and the malformation on which it depends is peculiar to a pos- 
terity physically degenerate. The blue disease described by Hip- 
pocrates (Be Morbis, lib. ii. Sec. v. page 485, Ed. cle Foe's, 1621) 
was probably some acute febrile affection. Galen, whose volumi- 
nous writings, with an excellent index, are still extant, and whose 
comprehensive mind embraced the whole range of medical science 
of the second century, makes no mention of it, so far as I can find. 
In the middle ages, as appears from a remark of Boerhaave (Bis- 
eases of the Humors, Acad. Lect. § 732), the common people believed 
the cyanotic to be the victims of evil spirits ; and it is probable 
that physicians, during this long period of superstition and intel- 
lectual lethargy, embraced the popular belief. 

On the revival of learning, pathological anatomy began to be 
more thoroughly and intelligently studied ; but it is evident that 
before the great- discovery of Harvey, in the 17th century, it was 
impossible to refer cyanosis to its true cause. In the latter part 
of the century so auspiciously opened by Harvey's genius, mal- 
formations of the heart were observed and described by some 
pathologists on the continent, in cases in which cyanosis must 
have been present ; but it is uncertain, from the brief records 
which they have left, whether any of them understood the de- 



676 CYANOSIS. 

pendence of this disease on the abnormal state of the heart. Boer- 
haave, in the beginning of the 18th century, attributes " a livid or 
black color diffused throughout the whole skin," evidently refer- 
ring to cyanosis, to " 1, a relaxation of the vessels, while the vis a 
tergo remains the same, or, 2, to a too sudden increased pressure 
behind, without a relaxation of the vessels." Yieussens, who was 
a contemporary of Boerhaave, and was more thorough in the ex- 
amination of morbid as well as healthy structures, narrated the 
history of a cyanotic patient, with a description of the malforma- 
tion, but the one who first gave particular attention to the blue 
disease was Morgagni. This Paduan professor, far excelling his 
predecessors in thoroughness of observation and accuracy of deduc- 
tion, published a theory in explanation of the disease which now, 
after the lapse of more than a century, has many adherents. In 
the same century with Morgagni, the 18th, but subsequently to 
his time, Drs. Pulteney, ¥m. Hunter, Baillie, Wilson, and Aber- 
nethy in Great Britain, and Jurine and Sandifort on the continent, 
may be mentioned among those who contributed to a knowledge 
of cyanosis by the publication of cases, with a description of the 
malformations. Yet, when the present century commenced, no 
monograph or dissertation had appeared on this disease ; and, not- 
withstanding the publication of cases from time to time, the profes- 
sion generally were almost totally unacquainted with its nature. 
]STo better idea can be given of the prevailing ignorance in reference 
to cyanosis at this period than by quoting from a case, narrated by 
Eibes in 1814. {Bull de la Fac. de Med., Paris, 1815.) The patient 
had some time previously received an injury of the finger. " Many 
physicians of Amsterdam," says he, " were at different times con- 
sulted on the subject of this affection, no one of whom understood 
its true cause, its essential character. One considered it as partaking 
of the nature of epilepsy, and caused by the irritation in the ner- 
vous system which the wound in the finger had produced. Others 
attributed it to the presence of intestinal worms. Some physicians 
pronounced it an injury of the liver or spleen. Many held it to 
be a scorbutic affection. One only believed it to be the result of 
an unknown organic disease." 

Since the commencement of the present century the blue disease 
has received a large share of attention. According to Forbes* $ 
Medical Biography, the first dissertation on this subject appeared 
in 1805, from the pen of Seiler, and from this time till 1832 no 
fewer than twenty-eight dissertations or monographs were pub- 



LITERATURE OF CYANOSIS. 677 

listed, either on cyanosis, or on malformations, which produce it 
or at least relate to it. In the list of writers are some of the most 
eminent names in the profession, as Louis and Bouillaud. The 
number who have written on this subject since 1832 probably 
exceeds the number of previous writers. Of those who have con- 
tributed most to our knowledge of the disease may be mentioned 
Farre, Chevers, and Peacock in Great Britain, Grintrac on the 
continent, and Moreton Stille in this country. Farre, Chevers, and 
Peacock wrote on malformations of the heart, alluding incidentally 
to cyanosis, but their writings contain valuable matter for statistics 
bearing on the latter subject. Farre's book was published in 1814, 
and is out of print ; Chevers published his papers in the London 
Med. Gazette, commencing in the year 1845, and running through 
several successive volumes. Peacock's Treatise was published in 
1858. It contains several original cases, previously narrated by 
him to the London Pathological Society. The paper by Moreton 
Stille, which has attracted much attention, especially in Europe, 
was his Inaugural Thesis, and was published in the Amer. Journ. 
of Med. Sci., in 1844. This paper relates entirely, in the words of 
the author, to "the laws of the causation of cyanosis." The only 
really complete statistical paper on the blue disease is that by M. 
Grintrac, published in 1824, in Paris, and embracing all the cases, 
which had been accurately reported up to that time, namely, fifty- 
three. He, indeed, exhausted the subject for the period in which 
he wrote, and were it not for the accumulation of material since, 
little could be added to his essay. 

Two theories in explanation of the occurrence of cyanosis have 
divided the profession ; the one attributing it to obstruction at 
the centre of circulation, and consequent venous congestion : the 
other, to admixture of venous and arterial blood through openings 
in the septa of the heart, or through the ductus arteriosus. The 
former of these theories originated with Morgagni more than one 
hundred years ago, and is essentially the same as that advocated 
by Stille. Stille errs in placing Morgagni among the advocates of 
the other system. The second theory, or that which attributes 
cyanosis to admixture of venous and arterial blood, is said by Dr. 
Peacock to have originated with Hunter, but its ablest supporter 
was Grintrac. Of late there are some pathologists who do not 
believe that either theory is sufficient to explain the cause of 
cyanosis, but that the true explanation lies somewhere between 
the two. Among the most conspicuous of these is Prof. \Yalshe 
of London. These theories will be considered in the proper places. 



678 CYANOSIS. 

Sex. — "Writers on cyanosis state that there is a preponderance 
of males to females affected with it. Aberle of Vienna says that 
two-thirds were males in an aggregate of 180 cases which he col- 
lated. In Grintrac's cases, 28 were males and 16 females; in 
Stille's, 41 were males and 31 females. The sex is recorded in 134 
of the cases collected by me, of which 78 were males, 56 females; 
and if those cases are excluded in which cyanosis was due to 
obstruction at the mouth of the pulmonary artery, the number of 
the two sexes is the same. In the five years commencing with 
1858, according to the mortuary returns, 207 died in this city 
from cyanosis, of which number 117 were males, 90 females. In 
England, for two years, 418 males died of cyanosis, and 273 females. 
Although statistics of different cities and countries agree in the 
fact of an excess of males over females, there does not appear to 
be that great preponderance of males, which the earlier writers on 
this disease believed to exist. 

Causes of the Malformations. — Mothers sometimes attribute 
the malformations, and probably correctly, to strong mental im- 
pressions felt during utero-gestation. The mother of a patient 
treated by Dr. Peacock stated that, " two months before her con- 
finement, she was frightened by seeing a child killed, and never 
recovered from the shock she sustained." (Malf. of Heart, p. 37.) 
In another case " the mother was much out of health, and stated 
that, when pregnant with the child, she was greatly alarmed by 
seeing a man who was dying of asthma." (Op. cit.,page 57.) In 
another instance the mother was frightened at the fifth month of 
pregnancy (page 41) ; and in still another case, recorded by Dr. 
Peacock, the mother, four or Rve months before her confinement, 
"was greatly alarmed by her husband, who was insane, standing 
over her for two hours with a loaded pistol." (Page 43.) 

Occasionally the malformation appears to be due to some vice 
or taint in the system of one or both parents. In a case quoted 
in the Gazette Medicate for December 28th, 1850, from another con- 
tinental journal, it is stated that " the mother, who had formerly 
suffered from rickets, gave birth to Rve children, all of whom died 
immediately or shortly after birth with symptoms of cyanosis. 
The father died at the age of thirty-six of phthisis." Dr. Peacock 
relates a case in which the father was livid, and had the " pigeon- 
breast" common in the cyanotic. In the history of a patient, 
which was communicated by Cooper to Farre (Case 166), it is 
related that " vices of conformation of the heart appeared to have 
been inherent in the family. Of 12 infants only 4 survived, and 



CAUSES OF THE M ALF OEM ATI OXS. 679 

more presented signs of heart-disease." Dr. Buchanan relates the 
history of a child which was the second that had suffered and died 
in the same family in the same way (Case 40). A patient treated 
by Mr. Leonard was the sixth child of the family, who had died 
at about the some age, with symptoms of cyanosis. Such instances 
are, however, exceptional. Ordinarily, the cyanotic have not only 
healthy parents but healthy brothers and sisters. 

A patient whose history is given by Dr. William Hunter was 
born at the eighth month, but in nearly all other cases the full 
period of uterine existence was reached. 

The opinion was expressed by Gintrac that the number affected 
with cyanosis, to the entire population, varies in different coun- 
tries. It is probable that the occurrence of the bine disease is not 
greatly, if at all, influenced by the nationality, but it is certainly 
dependent to a considerable extent on the condition of society. It 
is less frequent in a community in comfortable circumstances, and 
engaged in wholesome and quiet occupations. Pure air and out- 
door exercise, plain, nutritious diet, freedom from cares and 
anxieties, in fine, causes which promote the physical well-being, 
diminish the liability to an ill-formed and cyanotic offspring. 
And, conversely, impure air, improper and insufficient diet, grief, 
etc., increase the percentage of cyanotic cases. Hence, it is a rare 
disease in the rural districts, and comparatively frequent in the 
cities, especially in a large city like Xew York, which contains a 
numerous indigent and careworn population, living from year to 
year in the midst of agencies which operate stealthily but certainly 
to enervate the system and undermine the health. 

These remarks are abundantly substantiated by statistics. In 
Xew York City for the six years ending with 1860, there was one 
death from cyanosis to 436 deaths from all causes ; and in Brooklyn 
the proportion estimated for two years was about the same. On 
the other hand, in the State of Kentucky, which contains few large 
cities, and in the death reports of which cyanosis is included in the 
general term malformation, there was, during a period of five years, 
one death from malformation to 2469 from all causes. In the State 
of South Carolina, for three years, there was one death from cya- 
nosis to 5018 from all causes. In the State of Massachusetts, for 
two years, there was one death from cyanosis to 1136 from all 
causes, and two-thirds of the cyanotic cases occurred in the coun- 
ties of Suffolk, Essex, and "Worcester, which contain large cities. 
In London there was one death from cyanosis to 755 from all 
causes during a period of three years. On the other hand, in Eng- 



680 CYANOSIS. 

land, including the city of London, there was, for the ten years 
ending with 1857, one death from cyanosis to 1589 from all causes ; 
and in the rural districts of Monmouth and Wales there was only 
one death from cyanosis to 5578 deaths from all causes during a 
period of two years. 

Time of Commencement. — It is an interesting and somewhat 
remarkable fact that cyanosis, though dependent on a malforma- 
tion, does not always commence at birth, or, at least, that it does 
not exist in degree sufficient to produce the cyanotic hue till some 
time has elapsed after birth. In 138 of the cases of cyanosis which 
I have collected, the time at which lividity was first observed is 
stated as follows: In 97 it was within the first week, and generally 
within a few hours of birth. In the remaining 41 cases it com- 
menced as follows : — 

In 3 at 2 weeks. In 6 from 2 years to 5 years. 

"1 " 3 " " 1 " 5 " " 10 " 

" 2 " 1 month. " 6 " 10 " "20 " 

" 7 from 1 to 2 months. "1 " 20 " "40 " 

" 5 " 2 " 6 " " 1 over 40 years. 
"5 " 6 "12 " — 

"3 " 1 year to 2 years. 41 

In these 41 cases, in which blueness did not occur till after the 
age of one week, if the patient were less than two years old when 
it commenced, there was frequently no obvious exciting cause, 
but above this age, with three exceptions, such a cause is known 
to have been present. It is interesting to observe how trivial 
the exciting cause frequently is, and equally interesting to note 
how long patients have enjoyed good health, not having the least 
lividity, although the anatomical vice, to which the final develop- 
ment of cyanosis was due, had existed from birth. 

Dr. Theophilus Thompson relates, in the Medico-Chir. Trans., 
vol. xxv., the history of a lady, thirty-eight years old, who was 
well till an attack of Asiatic cholera, after which her health was 
permanently impaired. Two years before her death she passed 
through a course of fever, and from this time was cyanotic. In 
the Philadelphia Med. Examiner, June, 1850, Dr. Waters relates a 
case, in which cyanosis began at the age of six years in an attack 
of measles. In a case published by Mr. Napper, in the London 
Medical Gazette, 1841, the child fell at the age of six months, and 
from this time had cyanosis. A female, whose history is given by 
Prof. Tommasini, of Bologna, and quoted by Bouillaud, became 
cyanotic at the age of twenty-five in consequence of difficult par- 



SYMPTOMS. 631 

turition. In the London Lancet, 1842, Mr. Stedman relates a case, 
in which cyanosis began at the age of ten weeks in an attack of 
convulsions. In the American Journal of Med. Sciences, 1847, Dr. 
John P. Harrison published the history of a baker, twenty years 
old, in whom cyanosis began Hive years previously after great 
effort in carrying wood. Louis and Bouillaud quote from M. 
Caillot the case of a child, who became cyanotic at the age of two 
months in an attack of hooping-cough. Louis also narrates a case 
in which hooping-cough had the same effect at the age of twelve 
years. Ribes treated a child in whom the blue disease began at 
the age of three years from a severe contusion of the fingers. In 
a case related by Marx it commenced at the age of ten months 
from a blow on the back, inflicted by the mother. In the Medical 
Times and Gazette for 1855 Mr. Speer gives the history of a female, 
who at the age of thirteen years was put in a place requiring con- 
siderable exertion, and from this time was cyanotic. A patient, 
whose case is narrated by Cherrier, fell into a deep ditch in the 
winter season, and immediately after had a low fever, from which 
the blue disease commenced. In a case published by Tacconus the 
exciting cause was believed to be fright, in consequence of a fall 
from a great height, and in another, related by Bouillaud, it was 
a blow received on the epigastrium after the patient had passed 
the age of fifty years. Similar cases are related by Mayo and 
Peacock. 

It will be seen that the exciting cause of cyanosis is usually 
such as produces a profound impression on the system, and affects 
the action of the heart. Precisely in what way it operates to 
develop the disease has not been satisfactorily explained. Mr. 
Mayo conjectures, that in the case related by him there was pre- 
viously some compensation which ceased, or became inadequate in 
consequence of some change produced in the economy. Although 
cyanosis may not appear for months or even years, there is rarely 
improvement when it is once established. Appearances of amend- 
ment are deceptive. The disease when not stationary is progres- 
sive, and this explains the fact, that few survive the middle period 
•of life. 

Symptoms. — The symptoms of cyanosis vary in intensity in 
different patients, and in the same patient at different times, being 
milder if he is quiet and the mind calm, more severe if active, or 
if the mind is agitated. In mild cases, in a state of rest, they 
nearly or quite disappear, so that a stranger would not suspect 
that there was any serious ailment. They are aggravated by any 



682 CYANOSIS. 

cause which accelerates the action of the heart. In some, cyano- 
sis is increased by the most trivial disturbing influences, among 
which may be mentioned nursing, dentition, crying, coughing, and 
slight emotions of joy, sorrow, or anger. In more than one case it 
has been perceptibly increased by the stimulus of digestion, the 
color being deeper after a full meal than before. 

The cyanotic hue varies in different individuals from duskiness 
to a deep purple, almost black color. It is usually most marked 
in the visage, especially the palpebrae, cheeks, nose, and lips, in the 
ears, fingers, and toes, and upon the mucous surfaces. It is some- 
times, without any assignable cause, confined to a portion of the 
body. In a case related by Mr. Steel in the London Lancet, 1838, 
the upper part of the body was livid and ©edematous, and the 
lower part pallid and shrunken, and yet the malformation of the 
heart was that commonly present in cyanosis. In the London 
Medical Times, March 8th, 1845, copied from the Gazette Medicale, is 
the history of a child, six years old, in whom the color was deeper 
on the right than left side. There had been, however, hemiplegia 
of this side in infancy, but this had entirely passed off. On the 
other hand, in a case of rare malformation communicated by 
Cooper to Farre, in which the upper part of the system was 
supplied chiefly by arterial and the lower by venous blood, the 
discoloration was general. In rare instances livid maculse have 
been observed like those of purpura. 

Those affected with cyanosis have generally at birth been well 
formed and of the usual size, and in most cases, for a considera- 
ble period after birth, the appetite is good, bowels regular, and 
the system well nourished. But when cyanosis becomes so severe, 
as it does sooner or later, that its symptoms are rarely absent, 
digestion is imperfectly performed, and the body becomes either 
emaciated or stunted and puny. It may be stated, as a rule, that 
nutrition is in inverse proportion to the gravity of cyanosis. In 
thirty-three out of forty-one cases, in which the condition of the 
system, as regards nutrition, was recorded either a short time pre- 
viously to death or at the autopsy, the body was either considerably 
emaciated or else diminutive, and those who were well-nourished 
were usually such as had died early, or of some intercurrent dis- 
ease. 

In this connection may be mentioned two abnormalities which 
have been observed in the cyanotic. The chest is often flattened 
laterally with a projecting sternum, so as to present an appearance 
generally described in the records as " pigeon breasted." Some- 



SYMPTOMS. 683 

times the most prominent part is directly over the heart, and in 
one or two cases the sternum was observed to be deflected towards 
the left. In the majority of the records, however, no mention is 
made of the external appearance of the chest. 

The other abnormal development is more remarkable, and has 
not been satisfactorily explained. In twenty-eight cases it is 
stated that the tips of the fingers or toes, or both, were bulbous. 
This hypertrophy, if slight, is likely to be overlooked^ and that it 
was observed and recorded in so many cases renders it probable 
that it was present in a much larger number. In one case the ana- 
tomical character of this enlargement was examined, and was found 
to consist chiefly of hypertrophied connective tissue. The nails 
are often meurvated over the deformity. At a meeting of the Loud. 
Path. Soc. in 1859, Mr. Ogle narrated the history of a laborer, fifty 
years old, who had swelling, numbness, and lividity of the left arm, 
from pressure of an aneurism, and the fingers on this side were 
clubbed as in cyanosis. A patient whose history is related in the 
Glasgow Medical Journal, and who was believed to be cyanotic in 
consequence of a highly emphysematous state of the lungs, had a 
similar development of the tips of both fingers and toes. Why this 
bulbous growth should occur in consequence of the circulation of 
carbonaceous and non-oxygenated blood must at present remain a 
mystery. 

An interesting feature in cyanosis is the low grade of animal 
heat. The temperature of the body is in all cases below that of 
health. This is especially noticeable in the extremities. There 
has not been a sufficient number of accurate thermometric obser- 
vations to determine whether the internal heat is usually reduced. 
The following only have been recorded : Mr. Fletcher relates the 
history of a young man in the Medico-Chir. Trans., vol. xxv., in 
whom the thermometer placed in the mouth did not stand above 
80° Fahrenheit. Hodgson reports the case of a man, twenty-five 
years old, in whom the thermometer placed on the tongue rose 
to 100°, while in his own case it was two or three degrees below 
that term. In an experiment, recorded by Nasse, the instrument 
placed in the mouth fell little if at all below the healthy standard ; 
applied to external parts, it stood at about 21° Reaumer. 

The lack of heat is the source of great discomfort to a cyanotic 
patient. In mild weather he requires a fire to keep him warm, 
or an amount of clothing which to others would be intolerable, 
and in cold weather slight exposure strikes him with a chill. Nor 



634 CYANOSIS. 

can he increase his heat by active exercise, since his infirmity 
disqualifies him for this. 

Although the temperature of the surface is so low, the occur- 
rence of perspiration, sometimes profuse, is mentioned in several 
of the records. 

In severe cases of cyanosis the generative system is imperfectly 
developed. In the female, menstruation is scanty or delayed, and 
in the male the signs of puberty are feebly manifest. If the dis- 
ease is so mild that the symptoms are absent when the patient is 
in a state of repose, these organs attain nearly or quite their 
normal development. The catamenia have appeared as early as 
the age of sixteen years ; and a cyanotic patient treated by Cher- 
rier had two children, but they both died of scrofulous affections. 

The action of the heart is necessarily much affected. In mild 
forms of the disease, if the patient is quiet, this organ may beat 
with considerable slowness and regularity, but in all cases exer- 
cise or excitement, which in a state of health would scarcely have 
any appreciable effect on the pulse, embarrasses its movements, 
and produces palpitation. In severe cases palpitation is rarely 
absent, and the pulse is frequent, feeble, and often intermittent. In 
a large proportion of patients bruits are produced by the irregular 
circulation through the heart. 

The respiration corresponds with the action of the heart. It is 
accelerated in proportion to the frequency of the pulse. The suf- 
fering in this disease is largely due to paroxysms of palpitation 
and dyspnoea. These occur sometimes without any apparent ex- 
citing cause, and when the patient is quiet, but they are commonly 
induced by those causes which we have already mentioned as 
aggravating the symptoms of cyanosis. They come on suddenly, 
and are attended by increase of lividity, distension of the jugu- 
lars, and sometimes of the cutaneous veins, and by a sensation of 
present suffocation. They last only a few minutes, and are suc- 
ceeded by great depression of the vital powers. In infants, on 
account of greater nervous irritability, and feeble power of endu- 
rance, these paroxysms generally end in convulsions, which occa- 
sionally are fatal. . A cough is sometimes present, but it is usually 
slight. 

Pain is not a common symptom. Some of the patients com- 
plained occasionally of headache, with or without vertigo, and 
occasionally also of pain in the chest, but it is uncertain to what 
extent or whether these symptoms were dependent on the cyanotic 



SYMPTOMS. 685 

disease. The secretions do not appear to be affected, so far as lias 
been ascertained. The same may be said of the intellectual and 
moral faculties. In a case related by Dr. Chevers, the child was 
even said to be precocious. (Lond. Med. Gaz., vol. xxxviii.) The 
mind is capable of steady application and acquisition, as in health, 
provided that the emotions are not unduly excited. 

Those who are affected with cyanosis are liable to various forms 
of hemorrhage, but this liability, if we may judge from recorded 
cases, is greater in youth and adult life than in infancy. In two 
cases blood was vomited, in one passed by stool, in one it escaped 
from the gums, in two from the mouth, in eight from the nostrils, 
and in sixteen it was expectorated. Pulmonary phthisis was, 
however, usually present in these last cases. In the Western 
Journal of Medicine for 1829, an interesting case is related by Dr. 
Wm. M. Yoris of a girl, nine years old, in whom hemorrhage 
occurred under the scalp, producing great tumefaction, and nearly 
closing the eyelids. An incision was made, from which a pint and 
a half of dark blood escaped, and it was estimated that more than 
half a gallon was lost during the ensuing two weeks, at the expi- 
ration of which time the incision closed. The patient recovered 
from the hemorrhage but not from the cyanosis. 

Towards the close of life there is occasionally more or less 
anasarca, especially around the ankles, sometimes in the eyelids 
and face, and rarely to a certain extent over the whole body. In 
certain patients it coexists with effusion in the serous cavities. 

It is evident that one who is affected with the severer form of 
cyanosis is disqualified for the duties of active life. The sports of 
childhood and the useful labors of mature years require an exer- 
tion for which he is physically unfit. He has not the ability even 
to engage in animated conversation, for he is overcome by emotions, 
whether of joy or sorrow. He lives almost an idle spectator of 
the world around him, prevented by his infirmity from engaging 
in its pursuits. 

Intercurrent diseases, especially those of childhood, are badly 
tolerated ; but hooping-cough is the one which these patients are 
especially ill-fitted to endure. Still, they sometimes pass safely, 
not only through hooping-cough, but through some of the most 
dangerous febrile diseases. It is a question of interest, but about 
which little is known with certainty, whether these intercurrent 
affections are influenced by the cyanotic or venous condition of 
the blood. The symptoms of these affections are no doubt more 



CYANOSIS. 

alarming, mainly on account of the embarrassed action of the 
heart, and not on account of the state of the blood ; still it is 
reasonable to suppose that malignant and asthenic diseases are 
rendered worse by the lack of oxygen, and excess of carbonic acid 
in the circulating fluid. 

Probably cyanosis does not furnish immunity from any other 
disease, although this statement has been made by a high authority. 
Pokitansky says: " All forms of cyanosis, or rather all the diseases of 
the heart, great vessels, and lungs adapted to produce cyanosis, in a 
greater or less degree, cannot coexist with tuberculosis. Cyanosis affords 
a complete protection against it, and in this circumstance may be found 
an explanation of the immunity from, tuberculosis ichich many condi- 
tions of the system, apparently very different in their character, afford" 
(Handb. der Pathol. Anal, II. Bd.) This opinion of the distin- 
guished pathologist, notwithstanding his ample opportunities for 
observation and known accuracy as an observer, is not substan- 
tiated by statistics. So far from its being true, the low degree of 
vitality in cyanosis appears to favor tubercular deposition. I have 
records of twenty-six cases of cyanosis in which tuberculosis was 
also present, in several of which the lungs contained cavities. 
This is about thirteen per cent, of the whole number in my collec- 
tion — a large proportion, since so many die in early infancy, at 
which period the tubercular disease is not apt to occur. Cyanosis 
appears, also, to favor the development of cerebral diseases, espe- 
cially congestion and coma, as will be seen presently. 

Prognosis. — This is unfavorable. • Most cyanotic individuals die 
young. The age which they attain has been made the subject of 
statistical inquiry by Aberle. He states that in an aggregate of 
159 cases, 57, or 35 per cent., died before the end of the first year; 
108, or more than two-thirds, died before the age of eleven years; 
30 between the ages of 11 and 25 years ; and of the remaining 21, 
Rve only lived more than 45 years. 

The age at which death occurred is given in 186 of the cases 
collected by myself, as follows : — 

In 17 under the age of 1 week, • In 21 from 5 years to 10 years. 

" 10 from 1 week to 1 month. 
"12 " 1 month to 3 months. 
" 11 " 3 months to 6 months. 
» 17 " 6 " to 12 " 
" 12 " 1 year to 2 years. 186 

" 21 " 2 years to 5 " 

Sixty-seven, then, or more than one-third, died before the close 



41 " 10 


u 


"20 


20 " 20 


u 


"40 


4 over 40 


tc 





MODE OF DEATH. 687 

of the first year; 121, or more than three-fifths, before the age of 
ten years; only 24 survived the age of twenty years, and four the 
age of forty years. Of course, the duration of life depends on the 
nature and extent of the malformations. Some of these are such 
as render a speedy death inevitable. 

Mode of Death. — The mode of death is recorded in ninety-five 
cases, as follows : — 

19- died in a paroxysm of dyspnoea. 

10 " suddenly (the exact manner not stated). 

14 " in convulsions (infants). 
2 " of apoplexy. 
7 " from hemorrhage. 
6 " of phthisis (though, as we have seen, twenty others had 

this disease). 
2 " of exhaustion, without hemorrhage. 

10 " of coma. 
2 " of abscesses in the brain. 

1 " of each of the following diseases: cerebral irritation, 
congestion of brain, effusion in the cranial cavity, acute hydro- 
cephalus, paralysis from acute softening of the brain, dysentery, 
inflammation of heart, syncope, mucus in the air-passages, thoracic 
inflammation, choleraic diarrhoea, pneumonitis, bronchitis, scarlet 
fever, croup. One died in trying to walk, one after a spasmodic 
cough in pertussis, one after a long agony, one after an agony of 
ten or eleven hours ; one is recorded to have died gradually, and 
three quietly. 

The ten who are stated to have died suddenly, probably died in . 
paroxysms of palpitation and dyspnoea, which, we have seen, are 
easily excited, and of common occurrence in cyanosis. If so, this 
was the mode of death in 29 cases. Infants, with few exceptions, 
so far as appears from the records, died in convulsions. Nineteen 
died of cerebral affections, exclusive of convulsions, and in thirteen 
of these the cause of death was congestion, apoplexy, or coma. 
The hemorrhage of which seven died was probably, in most 
instances, dependent on phthisis, and six are said to have died 
directly of phthisis. We may, then, regard paroxysms of palpita- 
tion arid dyspnoea, convulsions, congestive affections of the brain, 
and phthisis, as common modes or causes of death in cyanosis. 

The malformations of the heart and great vessels which give 
rise to cyanosis are quite numerous. The following table exhibits 
their character and relative frequency: — 



688 CYANOSIS. 

CASES' 

1. Pulmonary artery absent, rudimentary, impervious, or partially obstructed 97 

2. Right auriculo-ventricular orifice impervious or contracted ... 5 

3. Orifice of the pulmonary artery, and the right auriculo-ventricular aper- 

ture, impervious or contracted . 6 

4. Right ventricle divided into two cavities by a supernumerary septum . 11 

5. One auricle and one ventricle . . . 12 

6. Two auricles and one ventricle 4 

7. A single auriculo-ventricular opening: inter-auricular and inter-ventri- 

cular septa incomplete 1 

8. Mitral orifice closed or contracted 3 

9. Aorta absent, rudimentary, impervious, or partially obstructed . . 3 

10. Aortic and the left auriculo-ventricular orifices impervious or contracted . 1 

11. Aorta and pulmonary artery transposed .14 

12. The cavse entering the left auricle 1 

13. Pulmonary veins opening into the right auricle or into the cavse or azygos 

veins 2 

14. Aorta impervious or contracted above its point of union with the ductus 

arteriosus ; pulmonary artery wholly or in part supplying blood to the 
descending aorta through the ductus arteriosus 2 

Total _ 164 

From the ahove table it appears that in more than one-half of 
the cases of cyanosis, the congenital vice which gives rise to it 
is located in the pulmonary artery. It is located also, in general, 
in that part of the artery which is nearest the heart. Its character 
is different in different cases. Sometimes there is an arrested 
development of this vessel, and in its place we find simply a 
ligamentous cord extending from the heart as far as the ductus 
arteriosus, while beyond this point the artery and its branches 
are pervious ; rarely the entire artery is ligamentous and, of course, 
impervious ; in other cases this vessel is open through its whole 
extent, but the part nearest the heart is so small as to be properly 
considered rudimentary ; in others still there is adhesion of the 
valves to each other as the chief congenital defect, and, finally, in 
rare instances the obstruction in the pulmonary artery is due to an 
adventitious membrane, which stretches across the vessel like a 
diaphragm. These last malformations, namely, adhesion of the 
valves and the formation of an adventitious membrane, are, doubt- 
less, due to inflammation occurring in the artery before birth, and 
some attribute the arrested development and ligamentous state of 
the vessel to the same cause. 

In most cases of cyanosis due to obstructive malformations, 
there is deficiency in the inter-auricular and inter- ventricular septa. 
This deficiency obviously results from the obstruction, for the septa 
are formed in the heart, after foetal circulation is established, and 



MORBID ANATOMY. 689 

the blood, being prevented by the vicious formation from flowing 
in its proper channel, necessarily passes to the opposite side of the 
heart. More or less blood being forced from one auricle or one 
ventricle to the opposite cavity, it is evident that a permanent aper- 
ture must result in the septum. The aperture in the septum ven- 
triculorum is ordinarily at its base ; in the septum auriculorum, it 
corresponds with the foramen ovale. 

In most of the obstructive malformations one and rarely two 
abnormal cardiac murmurs have been observed. The single mur- 
mur accompanies the ventricular contraction. As it has been ob- 
served in cases of complete as well as incomplete obstruction, it 
seems to be due mainly to the flow of blood through the apertures 
in the septa. 

Modes of Compensation. — In most cases of cyanosis, the con- 
genital defect is partially obviated by modes of compensation. 
In the most frequent malformation, that in which there is obstruc- 
tion in the pulmonary artery, and a considerable part if not all 
the blood flows directly from the right to the left side of the heart, 
the ductus arteriosus not only remains open, but is greatly en- 
larged, through which a current of blood enters the pulmonary 
artery from the aorta, and passing to the lungs is oxygenated. 
The bronchial arteries have also been found greatly enlarged, and 
it is believed that though they are the nutrient arteries of the 
lungs, the blood which they convey to these organs is decarbonized 
in its circuit through them. In a case published by Mr. Le Gros 
Clark, in the Medico-Chir. Trans., vol. xxx., the bronchial arteries 
were not only enlarged, but a "branch from the internal mammary 
artery, which accompanied the phrenic nerve, was nearly equal in 
size to the parent trunk, and expended itself principally in the ad- 
jacent adherent lung/ 5 Branches of the intercostal arteries have 
also been found enlarged, and entering the lungs, or connecting 
with vessels which entered the lungs. By such modes of compen- 
sation cyanosis is rendered milder, and life is prolonged. To these 
we must attribute the fact that some have very considerable mal- 
formation, and yet do not become cyanotic. 

Morbid Anatomy. — This, as regards the circulatory system, has 
been sufficiently dwelt upon. Xo chemical analysis, so far as I am 
aware, has yet been made of cyanotic blood. \Ye know that it is 
dark, its coagulability feeble, that it contains an excess of carbonic 
acid, and is deficient in oxygen. From the nature of cyanosis, it 
would be inferred that in many cases there is a degree of passive 
congestion in the cavities of the heart, and consequently in the 
44 



CYANOSIS. 

capillaries of the systemic system, giving rise to* more or less serous 
effusion. Statistics show that this is so. The quantity of pericar- 
dial fluid is in some patients increased. I have records relating to 
this fluid in fifty-one cases. Usually it was pure serum. In seven- 
teen the quantity was half an ounce or less, if we include in the 
number those in which the amount is expressed in such terms as 
" due quantity," " unusual amount/' and " small amount." In 
twenty-four cases the serum exceeded half an ounce ; usually esti- 
mated at from one to six ounces, but in two it exceeded the latter 
quantity. In one of the twenty-four the serum was sanguinolent. 
In two cases the records state that there was a small quantity of 
blood in the pericardium, and in the remaining patient the two 
pericardial surfaces were agglutinated by inflammation. 

In some of the autopies serous effusion was found in the pleural 
cavities, usually in connection with pericardial effusion, and in at 
least one instance the serum was tinged with blood. Old adhe- 
sions between the costal and pulmonary pleura were observed in 
a few instances. The condition of the lungs was recorded with 
more or less minuteness in one hundred and ten cases. Mention 
has already been made of the large number affected with tuber- 
cular disease, which was either confined to the lungs, or was chiefly 
exhibited in these organs. In thirty-five patients the records state 
that the lungs were of small size, either by compression, or some- 
times, apparently, by the continuance of the fcetal state over a 
greater or less portion of the organ. The compression was produced 
either by the distended pericardium or by effusion in the pleural 
cavities. In thirty-five cases the lungs presented a dark color. 
This hue in some specimens accompanied the unexpanded or fcetal 
state of the organ, but in others there was the normal inflation, and 
the dark color was due to engorgement or congestion. In other 
cases the lungs are stated to have been natural, except the color. 
In nine there was emphysema in a part of the lungs, in two pneu- 
monitis ; in two the color was pale, in one a bright crimson ; in one 
the lungs were larger than natural, in one the right lung was ab- 
sent, and in seventeen these organs were recorded healthy. 

I have records of the state of the liver in twenty-six cases, in 
sixteen of which it was enlarged, and in four of those enlarged it 
was congested. Congestion was present in eight other cases, in 
which no mention is made of the volume. The parenchyma had a 
natural appearance in nine cases, but in some of these there was 
enlargement. From these statistics it is probable that the liver is 
commonly enlarged in cyanosis, and not infrequently congested. 



THEOEIES EELATING TO ETIOLOGY OF CYANOSIS. 691 

In a few cases the condition of the other abdominal viscera is 
mentioned ; in some as healthy, in others as congested. There 
were fifteen examinations of the brain, in seven of which conges- 
tion is recorded, and in three abscesses in the cerebral substances, 
in one of which cases the lateral ventricle was also filled with 
pns ; in two there was softening of a portion of the brain, in three 
the brain was firm or compact, in three the quantity of fiuid in 
the cranial cavity exceeded the normal amount, and in one it was 
less. 

Theories Kelating to the Etiology of Cyanosis. — Although in 
nearly all cyanotic patients there are direct communications between 
the two sides of the heart, it is shown by many observations that 
these communications or apertures are not sufficient in themselves 
to produce cyanosis. This opinion was expressed half a century 
ago by Louis, who published an excellent monograph on the sub- 
ject of these communications, basing his remarks on an analysis of 
twenty cases. Since the publication of his paper, the belief has 
been pretty general in the profession, and observations continue to 
substantiate it, that, although the apertures maybe of considerable 
size, if the two sides of the heart, with their orifices and vessels, 
are in their normal state, so that they act symmetrically and 
without obstruction, cyanosis will not occur. In proof of the cor- 
rectness of this opinion many cases might be cited of a pervious, 
and some of a largely dilated foramen ovale without the cyanotic 
hue, cases which have been published in the journals since the 
appearance of Louis's monograph. Still, in cases of obstructive 
malformation, unless the obstruction is complete, cyanosis is more 
apt to occur in consequence of these apertures, for were they absent 
a larger amount of blood would be propelled through the narrowed 
orifice, and a larger amount consequently be oxygenated. 

Allusion has already been made to the two theories which pre- 
vail in the profession ; the one attributing cyanosis to the inter- 
mingling of venous and arterial blood ; the other to obstruction 
at the centre of circulation, and consequent venous congestion. 
There are serious objections to the acceptance of either theory as 
an explanation for all cases. That admixture of the two kinds of 
blood is not essential to the production of cyanosis, is apparent 
from the following facts. In one case in the Fourth Malformation, 
there was no communication between the two sides of the heart, 
and the ductus arteriosus was closed, so that admixture was impos- 
sible. Again, in the Eleventh Malformation, or that in which the 
aorta and pulmonary artery are transposed, the blue disease evi- 



692 CYANOSIS. 

dently does not depend on the admixture of the two currents. On 
the other hand, in this curious state of the heart, the more the 
admixture the less the cyanosis, since the only way in which the 
systemic current of blood can be arterialized is by passing to the 
opposite side of the heart. An argument against this doctrine 
may also be found in the fact that the modes of compensation are 
not such as in any way diminish or obviate the admixture. It is 
admitted that in the more frequent malformations cyanosis is in- 
creased by the apertures, which allow the intermingling of the 
venous and arterial currents, but it is more reasonable to consider 
the intermingling and the cyanosis as the direct results of the mal- 
formation, neither having the precedence of the other, than to 
consider that they are related to each other as cause and effect, or 
as proximate and remote results. Viewed in this light, the admix- 
ture must be considered simply a concomitant of the cyanosis. 

The second theory, that of venous congestion, has numbered 
among its advocates many who have given special attention to the 
subject, as Morgagni, Louis, and Stille, but it seems to have even 
less claim for acceptance than the theory of admixture. It has 
been seen that in nearly all cases of cyanosis the two sides of the 
heart communicate freely, so that if the current of blood meets 
with an obstruction, as it commonly does, it readily escapes to the 
opposite side where the artery is large and gives it free passage. 
In this way congestion, if not prevented, is greatly diminished. 
Again, it will be seen that, although certain of the viscera are 
frequently found at the autopsy more or less congested, congestion 
is not uniformly present in the organs, as it would probably be 
were it the proximate cause in all cases of cyanosis. 

Moreover, in some patients the malformation is not obstructive. 
The cavities and their orifices are of the normal size, and cyanosis 
is due entirely to malposition of the vessels. It cannot be said 
that in these cases there is venous congestion from arrest at the 
centre of circulation. If there is any congestion, it must be due 
to the fact that venous blood does not circulate as readily as the 
arterial in the capillaries. It is true that in the paroxysms of 
dyspnoea there is sometimes more or less congestion ; the disten- 
sion of the jugulars shows this, but it subsides with the paroxysms, 
and is probably no more than usually occurs when the respiration 
is greatly embarrassed. 

In fine, attempts to express the immediate pathological state 
producing cyanosis in the terms of a general law have failed. 
However plausible the above theories may appear in regard to 



TREATMENT. 693 

certain cases, there are others to which they are manifestly inap- 
plicable. Those who advocate these theories seem to lose sight of 
the obvious fact that the chief want of the economy in cyanosis is 
arterialization of the blood, and it is hardly supposable that there 
can be any correct theory of its causation which is not founded on 
this fact. With this want of the economy in view it does not 
seem difficult to express a theory in comprehensive terms which is 
applicable to all cases, such as the following: Cyanosis is due to 
vices or defects in the organism, usually congenital, which prevent the 
free and regular flow of blood to, through, or from the lungs. So com- 
prehensive a statement includes not only cases of malformation 
and malposition of the heart and its vessels, but also those few 
cases, in which the lungs are in fault. In most patients, as we 
have seen, the current of blood towards the lungs is obstructed, and 
the current of blood from the lungs, in those comparatively rare 
cases in which the malformation is on the left side. 

Treatment. — From the nature of cyanosis, it is evident that 
the treatment should be more hygienic than medicinal. The patient 
should be warmly clad and kept in a warm room, and all agencies 
calculated to embarrass or disturb the functions of the body or 
excite the emotions, and thereby accelerate the action of heart, 
should be studiously avoided. The diet should be nutritious, but 
simple and easily digested. 

Those who have attributed cyanosis wholly to apertures in the 
inter-auricular and inter-ventricular septa, and the consequent now 
of blood from the right to the left side of the heart, have considered 
it an important part of the treatment to keep the patient reclining 
on the right side, so as to diminish this now by the effect of gravi- 
tation. The reader, however, must be convinced from the nature 
of the malformations that little benefit can accrue from following 
such advice. Still, patients are sometimes less cyanotic and more 
comfortable in one position than another. In a case reported by 
Mr. Howship (Edin. Med. Journ., 1813) "the only easy and indeed 
comfortable position in which the child could remain was that 
usual in nursing. When erect, the dusky color of the face and 
neck became a dark blue." In a case related by Mr. Spackman 
(Liond. Med. Gaz.,1833), the patient was easiest on the hands and 
knees. Louis reports a case {die la Commun. des Cav., etc.) in which 
the selected position was with the head elevated; Wm. Hunter 
a case (Med. Obs. and Enq., vol. vi.) in which the patient avoided 
paroxysms by lying on the left side. Struthers and King each 
reports a case in which the patients seemed most comfortable while 



694 CYANOSIS. 

lying on the right side {Monthly Journ. of Med. 8ci.\ while, on the 
other hand, Prof. White of Buffalo {Buf. Med. Journ., 1855), and 
Dr. Jas. Carson (Amer. Journ. of Med. /SW.,1857), report cases in 
which position on the right side failed to produce any alleviation 
of symptoms. Other similar observations might be cited, but 
enough have been mentioned to show that no one position should 
be recommended for cyanotic patients. Some obtain most relief 
by lying on the back, others on the right side, others on the left, 
some when on the hands and knees, some when reclining on either 
side indifferently, while, finally, others suffer least when erect. 

There was a time when the paroxysms were treated by vene- 
section, but depletion has long since been abandoned. Physicians 
now rely on stimulants, antispasmodics, friction to the chest, and 
mustard pediluvia to relieve the urgent symptoms, although this 
treatment is but partially successful. 



SECTION V. 

SKIN DISEASES. 
CHAPTER I. 

EKYTHEMATOUS DISEASES. 

Under this head are included erythema, roseola, and urticaria. 
They consist in an active congestion, inflammatory it is believed, 
of the skin, which soon declines, with or without slight furfura- 
eeous desquamation. The color of the affected cuticle is a bright 
red in erythema, rosy in roseola, and a pale red in urticaria. 
Febrile symptoms often precede for a few hours the occurrence of 
the eruption, and abate as it appears. 

Erythema. 

The eruption of erythema occurs in patches of different sizes, the 
largest ordinarily not exceeding four or Ave inches in length and 
most of them have considerably smaller dimensions, their margins 
being in some instances diffused, and in others circumscribed and 
well defined. The patches are slightly swollen from engorgement 
of the capillaries of the skin and slight serous effusion, and are 
accompanied by a sensation of heat and itching. 

Erythema is idiopathic or symptomatic. The idiopathic form is 
subdivided into erythema simplex, intertrigo, and lseve. Erythema 
simplex is produced by external agencies of an irritating nature, 
as heat, cold, friction, chemical and mechanical irritants, applied to 
the skin. A common example of this form of the disease is the 
efflorescence about the anus in cases of infantile diarrhoea due to 
acidity of the evacuations. Erythema intertrigo is produced by 
the friction of opposing surfaces of the skin, and it therefore occurs 
mainly in the folds of the neck, about the groins, and behind the 
ears. This inflammation is sometimes slight, disappearing in two 
or three days with proper treatment ; in other cases the epidermis 
becomes denuded, the surface is tender and moist, and even super- 



696 ERYTHEMA. 

ficial excoriations occur. In severe cases the ulcers extend more 
deeply, and give rise to considerable purulent discharge, the skin 
and even subcutaneous connective tissue, being more or less 
infiltrated and indurated. The confinement of the perspiration, 
and the moisture, which is exuded between the folds of the skin, 
increase the inflammation. The effused liquid does not in ordinary 
cases stiffen linen, as in eczema. Erythema lseve is the name 
applied to the inflammatory hyperemia of the skin, which often 
occurs over cedematous parts. Its most common seat is about the 
ankles and upon the legs. In children it is most frequently 
observed in the oedema which results from scarlatinous nephritis 
and from heart disease. 

Symptomatic erythema, which results from a general or constitu- 
tional cause of a pyrexial character, has several subdivisions. The 
simplest and mildest form of it is erythema fugax, which comes 
and goes quickly. The erythema which occurs upon the features 
in acute meningitis is a typical example. It is common in various 
inflammatory and febrile affections. If the erythematous patch is 
circular, with normal skin in its centre, it is sometimes designated 
erythema circinatum, and- if the margin is well defined, margi- 
natum. Erythema papulatum, tuberculatum, and nodosum are 
applied to the same form of the disease, one or the other term 
being employed according to the stage or size of the eruption. In 
erythema papulatum the eruption begins as small red spots, which 
soon become papular, and attain a size varying from that of a pin's 
head to a split pea. It occurs especially on the neck, breast, arm, 
and back of the hand, and fades away, with a slight desquamation, 
in about three weeks. In erythema tuberculatum and nodosum 
the eruptions have a greater diameter, and are usually more promi- 
nent. In the latter variety they often have a diameter of two or 
more inches, and occur most frequently upon the anterior aspect 
of the leg. These three forms of erythema, which might be 
described as one, occur chiefly in young people. Erythema tuber- 
culatum is most common in servants, especially those recently from 
the country. The tumefaction is due to the effusion of serum in 
the corium, and, when the eruption has considerable prominence, 
also in the subcutaneous connective tissue. The color is at first a 
bright red, then dark red or purple, and it fades away like the 
discoloration of a bruise as the eruption declines. Rheumatism 
is often and diarrhoea occasionally associated with these forms of 
erythema, and rheumatic pains are occasionally present, as well as 
more or less febrile movement. 



TREATMENT. 697 

Prognosis. — This as regards the erythema is always good. An 
unfavorable result in any case is due to cachexia, or some coexist- 
ing disease. The duration of the milder forms is only a few hours, 
while the severer forms, as erythema nodosum, last two or three 
weeks. 

Diagnosis. — The ordinary forms of erythema are distinguished 
from erysipelas, by the absence of any very decided burning pain, 
and tumefaction of the integument, and tendency to spread, and 
by less marked constitutional symptoms. In those forms of 
erythema in which there is infiltration and swelling of the skin 
and subcutaneous connective tissue, the patches are distinguished 
from those of erysipelas by being multiple, of smaller size, less hot 
and painful, not extending, and presenting as they disappear the 
phenomena of a bruise. In urticaria the wheals that come and go 
suddenly with a peculiar stinging sensation, and the irritability of 
the skin by which these wheals can be produced by slight friction, 
differ in so marked a degree from the symptoms and appearances 
of erythema that the differential diagnosis of the two is easy. In 
roseola the eruption ordinarily occurs over a large part, if not the 
entire surface, in points and small patches with healthy skin 
between, and presenting a rosy instead of a bright-red color, 
characters which sufficiently distinguish it from erythema. Ery- 
thema when extensive is sometimes mistaken for the scarlatinous 
eruption, but the redness of the fauces, graver constitutional 
symptoms, vomiting, persistence of the eruption, etc., serve to 
distinguish the latter from the former affection. In cases of doubt 
it is proper to defer the diagnosis for a day or two, when if the 
rash is erythematous it will fade. Erythema sometimes occurs in 
the initial stage of variola, when on account of the grave general 
symptoms it may be mistaken for scarlatina. I have more than 
once known this mistake to be made in the hurried visit of the 
physician. A more careful examination would prevent this error. 
There is little danger of confounding erythema with measles, or 
the various papular, vesicular, or pustular skin diseases. 

Treatment. — Erythema fugax requires no special treatment, 
unless occasional dusting the surface with lycopodium or powdered 
starch. Those forms of erythema which are due to a mechanical 
or chemical irritant soon disappear when the cause is removed. 
In erythema around the anus, produced by the irritation of the 
urinary and alvine evacuations, the diaper should be changed as 
soon as soiled, and if the stools are frequent and acid, the alkaline 
treatment proper for the diarrhoea is useful also for the erythema. 



698 EOSEOLA. 

In inflammation from this cause as well as in erythema intertrigo, 
the following prescriptions will be found beneficial : — 

R. Pulv. zinci oxid., 

Lycopodii, aa. equal parts. Misce. 
To be frequently dusted upon inflamed surface. 

R. Zinci oxid. 5ij ; 
Glycerinse 3ij ; 
Liq. plumb, subacetatis 5jss; 
Aquae calcis ^vj to viij. Misce. 

In obstinate cases a weak solution of nitrate of silver, sulphate 
of copper, or, better, as it does not stain the linen, sulphate of zinc, 
will frequently be followed by immediate improvement. 

R. Zinci sulphat. gr. vj ; 
Glycerinse gij ; 
Aq. rosse ^iv. Misce. 
To be constantly applied between the folds of the skin on linen. 

Chlorate of potash, internally, to correct the acidity of the 
transpiration from the skin in protracted and obstinate cases, and 
in certain instances cod-liver oil and the syrup of iodide of iron, are 
called for. If the derangement of the system, upon which the 
erythema depends, appears to be of a rheumatic character, colchicum 
or alkalies may be required. Eiythema papulatum, tuberculatum, 
and nodosum occur most frequently in reduced states of the system, 
and therefore require tonics. 

Roseola. 

The term roseola is applied to rose-colored spots or patches ot 
greater or less extent, accompanied by a degree of febrile reaction, 
and often by redness with little or no swelling of the faucial 
surface. It is attended by a sensation of warmth and slight 
itching. The following groups and subdivisions embrace the 
recognized varieties of this disease. 

Roseola. 
Idiopathic, Symptomatic. 

Infantilis. Variolosa. 

^Estiva. Vaccinia. 

Autumnalis. Miliaris. 

Annulata. Rheumatica. 

Punctata. Arthritica. 

Cholerica. 

Febris continuse. 

Syphilitica. 



SYMPTOMS. 699 

The color of the eruption gradually fades from a rose red to a 
duller hue, and often disappears in two or three days. In other 
instances the eruption lasts a week or more. Roseola may occur 
in any season, hut it is most common, especially the idiopathic form, 
in the warm months. Those varieties of the idiopathic disease 
which are designated infantilis, eestiva, and autumnalis are the most 
common in early life. They are in reality indentical, or nearly so, 
and may he described as one disease. 

Symptoms. — Roseola infantilis, sestiva, or autumnalis may he 
partial, appearing upon the arms and legs, or general. It is often 
preceded by febrile movement, languor, and in those old enough 
to describe their sensations, pain in head, back, and limbs. There 
is great difference, however, in different cases as regards the 
severity of the prodromic symptoms. They may be absent or so 
slight as scarcely to be appreciable. Occasionally vomiting, diar- 
rhoea, or other symptoms of derangement of the digestive apparatus 
immediately precede the eruption. 

The eruption of roseola, when general, usually commences upon 
or about the neck and face, and in the course of twenty-four to 
thirty-six hours appears upon the rest of the surface. It bears con- 
siderable resemblance to that of measles. The patches are irregu- 
lar in shape, a quarter to half an inch in diameter, and, though of 
a rose color at first, they soon present a dusky hue as they begin to 
fade ; by pressure the redness disappears. In the majority of cases 
the eruption has nearly faded by the fifth day. The redness of the 
faucial surface, together with the itching or tingling, disappears 
with the subsidence of the rash. 

Roseola annulata is a rare disease. It commences with constitu- 
tional symptoms, which are slight or pretty severe, and which 
cease when the eruption appears. This occurs in the form of red 
circular spots, which enlarge to the diameter of an inch or there- 
about and assume the shape of rings inclosing healthy skin. 
The rash fades in a few days, often leaving a bruised appearance. 
The ordinary location of this form of erythema is upon the abdo- 
men, and about the thighs. In roseola punctata the eruption is of 
small size, and it occurs upon a large part of the surface. 

Symptomatic roseola, which appears in the course of various 
diseases, need only be alluded to. The diseases in which it is 
developed are, with the exception of syphilis, chiefly of an acute 
febrile or inflammatory character. This eruption is often really, as 
stated by Tilbuiy Fox, a rose-colored erythema, but in other in- 
stances it presents the typical form and appearance of roseola. Thus 



700 ROSEOLA. 

I have known it to occur about the eighth or ninth day of vaccinia 
in rose-colored spots over the whole surface, and producing much 
anxiety on the part of parents, lest impure virus had been em- 
ployed. 

Causes. — These are in a measure obscure. The delicacy of the 
skin in infancy and the active cutaneous circulation no doubt pre- 
dispose to roseola and erythema, and hence the frequency of their 
occurrence in acute febrile and inflammatory affections. Summer 
weather, with the derangements of system which it produces, has 
been in my experience much the most frequent cause of idiopathic 
roseola in young children in this city. In certain summers, as in 
that in 1868, a large proportion of the infants have been affected 
by it, and I have been led to consider it a favorable prognostic sign 
as regards the diarrhceal affections, which are so common in the 
warm months. 

Prognosis. — Roseola is always a mild and favorable disease. 

Diagnosis. — Roseola is distinguished from measles by the absence 
of catarrhal symptoms, the less degree of fever, less uniformity 
in the size of the eruption, and the absence of any history of con- 
tagion. Eoseola is distinguished from erythema by the smaller 
size of the eruption and its rosy or dusky red color. The 
boundary line, however, between the two affections is not well 
defined, and certain forms of roseola might be described as ery- 
thema. The general but punctiform efflorescence, increase of tem- 
perature, acceleration of pulse, and the peculiar appearance of the 
tongue and fauces, serve to distinguish scarlet fever from roseola. 
There is little danger of confounding roseola with urticaria, since 
the wheals of the latter appear in no other disease. 

Treatment. — This is simple. If roseola occur in connection with 
gastro-intestinal derangement or disease, the remedies which re- 
lieve the latter exert a curative effect upon the former. In all 
cases the state of the system should be inquired into, and any 
departure from a state of health corrected. Roseola needs no 
farther constitutional treatment. If there is itching or tingling 
of the surface, a lukewarm lotion, containing equal parts of liq. 
ammon. acetat. and mistura camphors, has been recommended, 
or a lotion containing a drachm of hydrocyanic acid to a pint of 
an emulsion of bitter almonds, used warm. The purpose of such 
lotions is simply to relieve the unpleasant sensation. Cold appli- 
cations, or others which would repel the eruption, should be 
avoided ; such an effect might be injurious. In cases of acidity of 



URTICARIA. 701 

stomach alkaline remedies are useful, and in certain cases tonic 
treatment is indicated. 

Urticaria. 

The name by which this disease is designated is derived from 
the term u?iica, the nettle, the sting of which produces this form 
of eruption. The eruption occurs suddenly in wheals or pomphi, 
attended by tingling and burning, and suddenly disappearing. 
Urticaria is often accompanied by no very decided general symp- 
toms, but in other cases there are febrile movement, and lassitude, 
with perhaps epigastric pain and headache. The wheals may 
occur over the whole body, but more frequently are confined to 
a portion of it. Their shape may be round, oval, irregular, or 
bandlike, and their length varies from a few lines to several inches. 
In one affected by urticaria the wheals can be readily produced by 
scratching or rubbing the surface. The eruption is thus clearly 
described by a recent writer: "At first a bright flush appears, the 
centre of this becomes slightly elevated, and pales, hence appears 
of lighter color ; the tint may be rosy, but more generally it is 
whitish." The margin of the wheal, the diameter of which 
varies, always remains red. This eruption appears to be produced 
by active congestion of the cutaneous capillaries, some serous 
effusion, and spasm of the muscular fibres of the skin. The 
effusion of serum in certain localities is quite apparent from the 
oedema which occurs. The subsidence of the eruption is without 
desquamation. Urticaria is ordinarily an acute disease. It is 
sometimes chronic in the adult, but rarely so in children. Several 
varities of it are described by dermatologists, according to the 
cause, appearance, and duration. 

Causes. — These are external and internal. Various irritants 
apart from the nettle applied to the surface produce the wheals, as 
the bites of certain insects and sometimes turpentine. The 
following are the principal internal causes, as summarized by 
Hillier: 1st, profound and sudden mental emotion; 2d, certain 
articles of diet, as shell-fish, pork, sausage, cheese, etc. ; 3d, certain 
medicinal substances, as copaiba, valerian, and turpentine; 4th, 
intestinal worms, though it is probable that these seldom operate 
as a cause; 5th, uterine ailments, as hysteria. 

Prognosis, Diagnosis. — The prognosis is good, though the chronic 
form is sometimes tedious and troublesome. The occurrence of 
the wheals and the possibility of producing them by friction serve 
to distinguish this disease from all others. 



702 PAPULAR DISEASES. 

Treatment. — In urticaria due to any recent ingesta of an irri- 
tating or indigestible character, an emetic of ipecacuanha is useful, 
followed by a saline, and better also alkaline aperient, as Rochelle 
salts. An aperient of this character is useful ordinarily in acute 
cases, attended by febrile reaction. The diet for several days 
should be simple, and such as is readily digested, as fresh beef, 
bread, or other farinaceous food, and milk. Occasionally the 
wheals appear periodically, when a few doses of quinine effect a 
prompt cure. After the above measures have been employed, the 
subsequent treatment, whether tonic or otherwise, depends on the 
condition of the patient. Little benefit accrues from local measures. 
Sponging the surface with cool water to which a little vinegar is 
added relieves, in a measure, the heat and tingling of the wheals. 



CHAPTER II. 

PAPULAE DISEASES. 

The three papulae, namely, lichen, prurigo, and strophulus, 
which are characterized by small and firm elevations upon the 
skin, occur in children ; but the two former are not common, and, 
as they do not differ in any essential particular from the same 
diseases in the adult, they will not be treated of in this connection. 
Strophulus, on the other hand, is a disease peculiar to children. It 
is known as the red gum or white gum according to its appearance, 
and also as the tooth rash. This eruption appears usually on parts 
which are exposed, as the face, neck, and extremities ; the papules 
being in some patients of the size, or even smaller, than a pin's head, 
while in other cases they are as large as a millet-seed. 

The varieties of strophulus described by dermatologists are : — 

S. intertinctus. S. candidus. 

" confertus. " volaticus. 

" albidus. " pruriginosus. 

The following are the characters of these varieties : S. intertinctus, 
papules a bright red, and occurring chiefly upon the cheeks, 
forearm, and back of hand; often intertinctured with blushes of 
erythema ; it lasts from two to four weeks, and is most common in 
young infants. S. confertus, papules numerous, and closely aggre- 



TREATMENT. 703 

gated, paler, continuing longer than in strophulus intertinctus, and 
likely to recur, appearing about the time of dentition, and most 
frequently upon the arm. Sometimes certain of the patches 
become chronic, slowly disappearing, and leaving the skin rough 
and dry. S. volaticus appears usually upon the arms and cheeks 
in patches of about a dozen, fewer or more, papules, which soon 
disappear. These patches reappear at intervals for two or three 
weeks, and are attended by heat and itching, though not intense. 
S. albidus, so called, should really be placed among the diseases of 
the sebaceous glands, and described under another name. It 
appears in the form of small white elevations as large as a pin's 
head, commonly upon the face and neck, and produced by disten- 
sion of the sebaceous glands with the secreted product. The term 
strophulus candidus is applied to large whitish papules, which 
appear upon the sides of the trunk, shoulders, and arms of infants 
of one year or thereabouts, and disappear in about one week. 
They are apt to be associated with the papules of strophulus con- 
fertus. S. pruriginosus is really a form of lichen, occurring chiefly 
over the age of one, and under that of eight or nine years. The 
papules, which are small and discrete, usually appear over a large 
extent of surface, ordinarily upon the back, front of the chest, the 
face and arms, and, as they are scratched from the itching, minute 
dark points of blood collect and dry upon their apices. This form 
of strophulus is more protracted than the others, and, in consequence 
of the irritation produced by the scratching, pustules of ecthyma 
often occur among the papules. The apparent cause of strophulus 
pruriginosus is a mode of life which impoverishes and vitiates the 
blood, such as uncleanliness, residence in damp, dark, overheated, 
and overcrowded apartments. Atmospheric heat also operates as 
a cause, and it is a not infrequent disease in the cities during the 
summer months. 

The various eruptions included under the term strophulus have 
such different anatomical characters, that a proper classification 
would locate some of them in other groups of skin diseases. One 
form of it, as we have seen, is produced by distension of the seba- 
ceous glands ; in other and the majority of cases, as appears from 
the recent observations of Mr. Fox, its seat is the sweat glands, 
and in others still the papillary layer of the skin as in lichen, the 
papules being produced by an exudation. 

Treatment. — Personal cleanliness, with frequent change of linen, 
and daily ablution without the use of soap, should be enjoined. 
Local irritants, which might aggravate or cause the disease, should, 



704 ECZEMA. 

so far as practicable, be removed. Alkalies in cases of acidity of 
the primce vice, and occasionally mild aperients, are required ; the 
food should be bland, but nutritious, and if the child is nursing, it 
may be necessary to attend to the health of the wet-nurse. Favor- 
able hygienic conditions important for the successful treatment of 
all forms of strophulus are especially required in strophulus pruri- 
ginosus. Nutritious diet, fresh air, quinine, iron, cod-liver oil, etc., 
should be prescribed for those affected by it. The following 
formula is recommended for sponging the surface in cases of 
strophulus: — 

R. Sodae carbonat. 9j ; 

Glycerinse 5ij ; 

Aq. rosse 3vj. Misce. 



CHAPTER III. 

ECZEMA AND SCABIES. 

Two other forms of cutaneous eruption should be treated of 
among the diseases of children, since they are much more frequent 
in them than in adults, although they occur at any age. The 
diseases alluded to are eczema and scabies, both placed by derma- 
tologists in the group of vesiculse. 

Eczema. 

This is one of the most common inflammatory affections of the 
skin. It constituted one-third of Devergie's cases and one-sixth 
of Hillier's. It is, as remarked by Niemeyer, the analogue of 
catarrh of mucous surfaces. It is accompanied by a discharge of 
a serous appearance, which, confined at first by the epidermis, 
'usually lifts it at numerous points, forming small vesicles. The 
vesicles are fragile, soon rupturing, and as they disappear the 
surface underneath is seen to be red and abraded. The fluid has 
the property of stiffening linen, and as it dries it is succeeded by 
a crust of moderate thickness and a light-yellow color. The 
crusts are composed mainly of inspissated pus and epithelial cells 
intermixed with granular matter. 

Eczema is attended by a sensation of heat and itching. The 
vesicles may appear only at the commencement, or if the epidermis 
is not entirely destroyed there may be successive crops of them. If 
the epidermis is destroyed, or does not furnish sufficient resisting 



ECZEMA. 705 

power, the liquid escapes immediately on the free surface, and 
vesicles are not produced. The discharge is irritating, and the 
contiguous surface with which it happens to come in contact is 
usually irritated and reddened by it. While these superficial 
changes occur, the deeper portions of the integument become 
thickened and infiltrated. 

Eczema occurs in various parts of the body, and it is sometimes 
designated, according to its locality, as faciei, capitis, etc. In its 
acute stage it is usually attended, especially if the patches are of 
large size, with febrile movement. The patient ordinarily presents 
a pallid, cachectic, or strumous aspect, has a poor or capricious 
appetite, slightly furred tongue, and disordered, usually constipated 
bowels ; but the general condition and the symptoms vary con- 
siderably in different cases. 

There are three varieties of eczema, namely, simplex, rubrum, 
and impetiginodes. Eczema simplex is most common in the 
summer months, being produced by the heat of the atmosphere. 
External irritants, applied to the skin, as strong soap, sometimes 
cause it. The patient complains, perhaps, of febrile symptoms, and 
soon an erythematous patch of greater or less extent appears, upon 
which a cluster of the vesicles of eczema arise. These break, 
forming slight crusts, which are soon detached, and the disease 
declines, or it may continue longer, with a successive eruption of 
vesicles. 

Eczema rubrum is a more severe form of the disease. The fever 
and the local symptoms are greater than in the preceding variety, 
and the eczematous patch presents the appearance of a more 
intense inflammation. The vesicles, which are often so minute as 
to be with difficulty recognized, and so numerous as to become 
confluent, are soon ruptured, and their contents, with the secretion 
and exudation from the surface, dry into yellowish or brownish- 
yellow scabs. The discharge is more irritating, as it is more 
abundant, than in eczema simplex, and the adjacent skin usually 
is inflamed from its contact. Its most common seat is about the 
flexures of the body, but it not infrequently extends to a greater 
or less extent alone: the surface. 

Eczema impetiginodes is common in young, debilitated children, 
in whom, in consequence of the cachexia, inflammations, of what- 
ever character, are apt to be suppurative. This form of eczema 
presents at first the symptoms and features of eczema rubrum, but 
the transparent liquid of the vesicles soon becomes opaque, from the 
generation and admixture of pus corpuscles. The crusts, which 
45 



706 ECZEMA. 

form from the rupture and desiccation of the vesiculo-pustular 
eruption, are thick and greenish-yellow, and in infants the 
sebaceous glands, which are involved in the inflammation, pour 
out an abundant secretion, increasing the thickness of the crusts. 
This form of eczema is most common in infancy, and its usual seat 
is upon the scalp. 

Other varieties of eczema are described by writers. When the 
inflammation does not entirely abate, but sufficient of it remains 
to cause scaliness, it is designated squamosum. This form may 
continue many months. Eczema may also become chronic, with a 
free and irritating discharge, the eczema ichorosum of authors. 
"When eczema is severe, or protracted, various structural changes 
occur in the inflamed integument, as fissures, oedema, papillary or 
warty out-growths, hyperplasia of the connective tissue, and sub- 
varieties of the disease are described by writers, according to these 
characters. It is seen, therefore, that there is considerable varia- 
tion in the appearance of an eczematous eruption, but its distinc- 
tive feature is the occurrence of a discharge of a serous appearance 
from the inflamed surface, which lifts the cuticle, and appears to 
the eye in the form of minute vesicles. This discharge is some- 
times insignificant, almost absent, but the form of the vesicles, 
although they may abort, can be made out in the commencement 
of nearly all cases. 

The eczema of infants is of most interest to us, as it is not only 
so common, but is one of the most troublesome of the cutaneous 
affections. It is really in its commencement in most cases an 
eczema simplex, or rubrum, or a combination of the two. Its 
seat is upon the scalp, behind the ears, upon the face, and in the 
flexures of the joints. Unless properly treated, it frequently 
becomes chronic, lasting several months, being usually, when pro- 
tracted, an eczema impetiginodes. The health of the child after a 
time suffers. It becomes more pallid, its flesh more soft and flabby, 
and the appetite impaired. The heat, itching, and pain increase 
the discomfort. 

Diagnosis. — Eczema presents in different instances so different 
an appearance that it is not always readily diagnosticated. It will 
aid in its diagnosis to recollect that it is in its nature a moist 
disease, affecting primarily and chiefly the upper portion of the 
derma and the malpighian layer, and although it may, at present, 
present a dry or scaly appearance (E. squamosum) yet its history 
will show that there has been a discharge or moisture. In a large 
proportion of cases, the physician is not able to detect vesicles, 



TREATMENT. 707 

since they are fragile and transient, breaking in the first thirty- 
six hours, and not reappearing. Still, when vesicles are absent, 
we sometimes observe around the margin of the patch an appear- 
ance which indicates that they have been there. Their minuteness 
is occasionally such that they may escape notice, on a cursory 
inspection, when they are present and well defined. Acute ec- 
zema, affecting a considerable extent of surface, is attended by 
decided febrile movement, and might be mistaken for one of the 
eruptive fevers, but the absence of certain distinctive appearances, 
which characterize these fevers, and the speedy appearance of 
vesicles and moisture, establish the diagnosis. Eczema can be 
readily diagnosticated from ordinary erythema, which is a super- 
ficial inflammation without moisture. The location of erythema 
intertrigo serves for its diagnosis, as it is evidently produced by 
the attrition of opposite surfaces of the skin. Moreover it lacks 
the vesicular eruption, and the discharge does not stiffen linen like 
that of eczema. Lichen, when acute, presents some resemblance 
to eczema, but it is dry and papular, the papules though small 
being detected by the finger as well as sight. The large and 
irregular phlyctaena, intense inflammation, and oedema, and mode 
of extension of erysipelas, large, scattered, and non-inflammatory 
vesicles of suclamina, scattered and accuminate vesicles, without 
surrounding inflammation of scabies, are so different from the 
eczematous eruption that the differential diagnosis is readily 
made. Herpes circinatus can be distinguished from eczema by its 
circular shape, larger size, and greater permanence of the vesicles, 
and the delicate, branny scales, which consist rather of epithelial 
cells than the product of exudation as in eczema. 

Treatment. — Hardy believes that there is a diathesis which 
manifests itself in certain cutaneous eruptions, especially eczema, 
pityriasis, psoriasis, and lichen. This diathesis he designated 
dartrous, and those who have it may seem to have good general 
health, but not in reality. Their skin is readily affected by 
irritants ; it is dry, the perspiration being deficient, and it is liable 
to pruritus. The dartrous diseases of the skin are non-contagious, 
often hereditary, prone to reappear and invade new portions of 
the surface, protracted in their nature, accompanied by itching, 
and healing without cicatrization. According to this theory, there- 
fore, the predisposing cause of these diseases is to be found in the 
diathesis, or the state of the blood, but in ordinary cases there are 
certain exciting causes, which may be found in the occupation, 
mode of life, or hygienic conditions. The mucous surfaces are 



708 ECZEMA. 

often also affected, a dartrous bronchitis, leucorrhcea, etc., occurring. 
Such is the theory of Hardy and the French school. 

That there is in a large proportion of cases of eczema, and of 
the other diseases alluded to above, a diethetic state by whatever 
name known, underlying and causing the eruption, is not, however, 
a new belief; and hence the term herpetic diathesis, or dyscrasia, 
by which this state has long been designated. 2S~ot infrequently, 
especially among the city poor, eczema is obviously one of the 
protean manifestations of the scrofulous diathesis, the eruption 
disappearing under anti-strumous remedies. It is a matter of 
importance as regards the therapeutics to recognize a constitutional 
cause in eczema, whether it be a diathesis, or, as is not infrequently 
the case, is of a more transient nature, the result of some influence, 
which temporarily impairs the health. But while it is, therefore, 
apparent that internal treatment is ordinarily required for the 
successful treatment of eczema, there are certain cases in which 
the system is not in fault, and local measures alone are required, 
as when the eruption is due to the direct effect of the sun's rays, 
or friction. 

General Treatment. — In most recent cases of eczema, great 
benefit results from an occasional purgative dose. This is most 
useful in the sthenic cases, when accompanied by considerable 
pyrexia, a full pulse and troublesome pruritus. An occasional 
dose of calomel, or a saline purgative, should be given. By its 
derivative effect it diminishes the intensity of the cutaneous 
inflammation, and the patient experiences a degree of relief from 
the itching. In feeble infants the hydrarg. com. cretse, followed 
by syrup of rhubarb, is sometimes preferable. The purgative 
often requires to be repeated once or twice weekly. 

If the child is scrofulous, the proper internal remedies for daily 
use are cod-liver oil, and the syrup of the iodide of iron. The 
constitutional state, whatever its exact character or cause, is most 
frequently one of debility, and therefore tonics, vegetable and 
ferruginous, are useful. "We have in addition one internal remedy, 
the value of which is acknowledged by all dermatologists, namely 
arsenic. Wilson regards it a specific for this disease. The follow- 
ing is the formula which he recommends, and which will be found 
useful for ordinary cases: — 

I£. Vini ferri, 

Syrup tolutani, aa §ss ; 

Liq. potas. arsenit. v\ xxxij ; 

Aquas anethi §j. Misce. 



LOCAL TREATMENT. 709 

Dose, one drachm, with or after the meals, three times daily. 
An infant from six to twelve months old can take from one to 
two minims of Fowler's solution. Prominent among the imme- 
diate and preventible causes of eczema is some error of diet. If 
the patient is a nursing infant, the state of the health of the wet- 
nurse should be attended to, and if it is in fault, she should be 
placed upon tonic or other treatment. "If," says Mr. Fox, "the 
child is being brought up by hand, corn flour, and other purely 
starchy compounds, I think should be avoided. Fine baked flour, 
and milk wheat phosphates, is perhaps the best compound." 

Local Treatment. — As the skin in eczema is in an inflamed 
and sensitive state, and easily irritated, soothing local treatment 
is required in recent or acute eczema. In the commencement of 
the eruption, one of the following formulae will be found useful: — 

R. Liq. plumbi subacetat., 
Yini opii, aa £j ; 
Ung. sambuci sjj. 

To be applied frequently over the eczematous patch. Simple 
cerate may be used in place of the orange flower ointment: — 

^. Gum camphor gss ; 

Alcohol q. s. Misce. 
Adde 

Zinci oxid., 

Pulv. amyli, aa, 3iv. 

To be dusted upon the surface. This powder is useful both in 
treating the eruption and for the burning sensation. A simple 
water dressing, or bathing with milk and water, is also useful, 
when the inflammation is in its first stages, and active, and the 
local symptoms are severe. The following prescription employed 
by Mr. Fox is also beneficial in such cases: — 

K. Sodse borat. 9ij ; 

Zinci oxid. 3J ; 

Liq. plumb, snbacetat. ^ij ; 

Aq. calcis §tj to 5 viij . Misce. 

When the eruption has continued for a little time, and the 
pyrexia and local symptoms are somewhat moderated, the pre- 
parations of zinc are most highly esteemed for local treatment 
both in this country and in Europe. In Germany, on the other 
hand, preference is given to the milder mercurial ointments, as the 
white precipitate, considerably diluted. But the result of the 
zinc treatment is ordinarily satisfactory, and it should always be 
employed, when the eruption involves a considerable extent of 



710 ECZEMA. 

surface. After the crusts have been softened by a poultice or 
glycerine, and to a considerable extent removed, the following 
ointment should be thickly applied to the surface, two or three 
times daily. E"o soap or other irritant should be employed after 
the treatment has been commenced, but any bathing which may 
be required should be by simple water, milk and water, mucilagi- 
nous water, or bran water. The following is also a good formula 
for ordinary cases of eczema : — 

R. Zinci oxid. 5ij ; 
Glycerinae g j ; 

Liq. plumbi subacetat 5jss ; 
Aquae calcis Jviij. Misce. 

If the burning and itching remain a troublesome symptom, 
notwithstanding this treatment, one of the following washes may 
be frequently applied in addition: — 

R. Potas. cyanid. gr. xxiv; 
Aquae § viij . Misce. 

I£. Sodae borat. 5y ; 
Aq. lauro-cerasi ^j ; 
Aq. sambuci ^jss. Misce. 

I£. Liq. ammoniae acetat, 1 part ; 
Aq. camphorae, 2 parts. Misce. 

If the above treatment fail to relieve eczema, or if the improve- 
ment is slow and unsatisfactory, the ointment of the nitrate of 
mercury, or of ammoniated mercury, will frequently produce 
speedy improvement and cure. I have noticed the most benefit 
from it in chronic cases, in which the amount of inflammation 
was quite moderate. Niemeyer says, "The topical remedies, 
which I would recommend before all others, are the white pre- 
cipitate in the form of an ointment (hydrarg. ammoniat, 3J adipis 
3j) and corrosive sublimate in weak solution (hydrarg. bichlor. gr. 
j-ij, aquae destillat. 3j), . . . since in the great majority of cases 
they amply suffice to effect a rapid and complete cure, even of the 
most obstinate forms of eczema." The preparations of lead and 
zinc, he believes, " stand next in virtue to the white precipitate 
salve, and the solution of corrosive sublimate," as remedies for 
eczema. In the foregoing remarks no allusion has been made to 
those cases of eczema which are due to the syphilitic dyscrasia. 
Evidently mercurials are essential to the successful treatment of 
this form of the disease, and the white precipitate, citrine, or simple 
mercurial ointment, properly diluted, should always be prescribed 



SCABIES 



711 



for local treatment of such cases instead of the preparations of 
zinc or lead (Art. Syphilis). 

Scabies. 

The diseases of the skin previously considered are non-conta- 
gious. Scabies, on the other hand, is one of the most contagious 
diseases by contact. It is produced by an animal parasite, known 
as the itch-mite, or acarus scabiei. The inflammation is caused by 



Fig. 1. 



Fig. 2. 



Fig. 3. 





Fig. 4. 









Fig. 1. The itch animalcule, acarus scabiei, viewed upon the back, showing its figure and the ar- 
rangement of its spines and filaments. The female, which is somewhat larger than the male, has a 
length of 1-S0th to l-60th of an inch. 

Fig. 2. The foot and last joints of the leg of the itch animalcule. 

Fig. 3. The male itch animalcule, viewed upon the under surface, showing its legs and lobulated feet. 

Fig. 4. Ova of the itch animalcule. 



the female only, which burrows, making for itself a canal, or 
cuniculus, in which its eggs are deposited. The male does not 
burrow, but conceals itself under the scales or crusts which result 
from the inflammation produced by its partner, or it burrows only 
sufficiently to produce a covering and shelter. From observations 
made by Eichsteclt, Gudden, and others, the female has been found 
within half an hour after being placed upon the skin to have con- 
cealed herself in the epidermis, and the cuniculus which she con- 
structs is arched and tortuous, and four or five lines in length, 
shorter or longer. The acarus has the shape of a tortoise. It can 
when fully grown be detected by the eye as a minute whitish point. 
The young acarus has six, the mature eight, articulated legs, with 
suckers upon the two anterior pairs, and hairs on the posterior. 
The head, which can be elongated or retracted, is provided with 
two jaws. The upper surface is covered with spines directed back- 



712 SCABIES. 

wards so as to prevent retrogression in the burrow. She leaves 
behind her in the cuniculus, as she advances, her moulted skin, 
excreta, and eggs, which hatch on the eleventh day. The mother 
acarus is always found at the remote end of the burrow, where it 
can be seen by the unassisted eye as a minute whitish or sometimes 
brownish speck, and from which it can be lifted by the point of a 
needle to which it clings. The cuniculi can also be seen by the 
naked eye, looking, says Kiemeyer, like the "scars of needle 
scratches," and containing the young acari in various stages of 
growth. 

The acarus by its burrowing produces an irritation, and trouble- 
some itching, which is the chief cause of the suffering of the patient. 
At the point where the acarus penetrates the cuticle the inflam- 
mation gives rise to a single, small, and accuminate vesicular or 
papular eruption, the cuniculus extending away from it. "We 
often find ecthymatous pustules and abrasions intermingled with 
the vesicles, the result of the frequent scratching. The itching is 
most intense, and the acarus most active, at night, when the patient 
is warm in bed. Scabies most frequently appears, especially in 
adults, first upon the hands, between the fingers, where the skin is 
thin, and it extends thence along the forearm, and over the thighs 
and abdomen. In children it not infrequently occurs upon the 
buttocks, thighs, feet, etc., while the hands and forearm escape. 

Diagnosis.- — Correct diagnosis is important, because the treat- 
ment required is different from that in any other exanthem, and 
because the suspicion of having this disease always renders one 
solicitous to know the exact nature of the eruption. Scabies can 
be diagnosticated from those diseases for which it might be 
mistaken by the following characters: its occurrence where the 
cuticle is thin and delicate, as between the fingers, along the ante- 
rior aspect of the forearm, upon the abdomen, thighs, and inside 
of the feet ; small size, accuminate shape, and isolated position 
of vesicles ; the intermingling with the vesicles of other forms of 
eruption, as papules and pustules, and the presence of linear scars 
and abrasions produced by the scratching ; itching most intense 
at night; absence of fever; absence of the disease from posterior 
aspect of body and arms, and from head and face. Scabies may 
be distinguished by the vesicular character of the eruption from 
all other exan thematic affections except eczema, sudamina, and 
herpes. Eczema is most common on the scalp and face, where 
scabies does not occur, and unlike scabies its vesicles are round 
and thickly aggregated in clusters; in eczema there is a smarting 



TREATMENT, 713 

or prickling sensation very different from the intense itching of 
scabies. In herpes the vesicles are large, rounded, and in clusters, 
and attended by a burning or pricking sensation, with but little 
itching. The eruption in sudamina is vesicular and discrete, as 
in scabies, but it is globular, and accompanied by no itching or 
other local symptoms. 

Treatment. — As scabies is due to a species of acarus which 
burrows in the epidermis, it can only be treated successfully by 
measures which destroy this animalcule. If it is destroyed, the 
disease gets well of itself. Sulphur has been employed for a long 
period for this purpose, since sulphurous acid, which is evolved 
from the sulphur, is destructive to the animalcule. The unguen- 
tum sulphuris, if thoroughly applied, will rarely fail to eradicate 
the disease. The internal use of sulphur aids the external treat- 
ment, since a portion of the gas which is generated escapes through 
the pores of the skin. The chief objection to the employment of 
sulphur is its exceedingly unpleasant odor, which is noticeable, 
however disguised by perfume. Sulphur or any other substance 
employed externally has more effect if it is preceded by a bath, 
which softens the epidermis, and therefore favors the entrance of 
the remedy into the pores of the skin and the cuniculi. 

Helmerich/s ointment is very effectual in the treatment of 
scabies. It consists of two parts of sulphur, one of carbonate of 
potash, and eight of lard. "M. Hardy afterwards perfected the 
method, so as radically to cure the disease in two hours. He 
proceeds in the following manner: The patient hrst undergoes a 
friction of his whole body for half an hour with soft soap, in order 
to cleanse the skin and break up the burrows ; a warm bath of an 
hour's duration follows, during which the skin is thoroughly 
rubbed, in order to complete the destruction of the burrows ; after 
which frictions for half an hour and upon the whole surface are 
practised with Helmericlr's ointment. This completes the cure. 
Out of four hundred patients subjected to this treatment, only 
four returned to the hospital." (Stille's Therapeutics, etc., vol. ii. 
page 516.) 

M. Albin Gras experimented with different substances, in order 
to ascertain their relative destructiveness to the acarus. The fol- 
lowing table gives some of the results of his experiments : — ■ 

Immersed in pure water the acarus was alive after three hours. 

" saline " " moved freely after three hours. 

" Goulard's solution the acarus lived after one hour. 

" olive, almond, or castor oil the acarus lived more than two hours. 



714 SCABIES. 

Immersed in lime-water the acarus died in three-fourths of an hour. 
" vinegar " " twenty minutes. 

" alcohol " " " " 

" turpentine " " nine " 

" iodide of potassium the acarus died in four to six minutes. 

It is seen that vinegar, lime-water, alcohol, turpentine, and 
iodide of potassium destroy the acarus in a short time. They 
may be employed in the same manner as the sulphur ointment. 
Camphor is also destructive to this animalcule, and the linimentum 
camphorse, thoroughly applied, is a good remedy for uncomplicated 
scabies. 

In order to avoid the odor of sulphur which is so offensive, one 
of the following ointments may be employed, if the patient is 
fastidious. 

$. Unguent, hydrarg. ammoniat. ^j ; 
Moschi gr. ij ; 
01. lavendul. gtt. ij ; 
01. amygdal. gj. Misce. (From Wilson.) 

This should not be used if the scabies is extensive, but the fol- 
lowing, which is recommended by Bazin, and is said to cure the 
disease with three applications: — 

R. Anthemis pulv., 
Adipis, 
01. olivse, aa ^j. Misce. 

In cases which have been protracted, and in which ecthymatous 
and other secondary eruptions have occurred, the scabies can 
ordinarily be readily cured, while the other eruptions remain and 
disappear more slowly. A knowledge of this is important, since 
the sulphur, or other ointment employed for the cure of scabies, 
should be discontinued when the itching ceases, and vesicles no 
longer appear, and tonic, or other treatment appropriate to cure 
these secondary eruptions, should be employed instead. The 
sulphur ointment continued, after the scabies is cured, does harm, 
as it irritates the cuticle. 



APPENDIX 



The modes of preparing milk for infants, which are described in the 
chapters relating to feeding, are simple, and are therefore preferable to 
more difficult processes. If the milk thus prepared disagree, other 
formulae may be employed which furnish a product more closely re- 
sembling human milk. The two following, which are extracted from 
Routh's Treatise on Infant Feeding, are among the best. In both the 
amount of casein is diminished and of sugar increased. First, Prof. 
Falkland's method : — 

" One-third of a pint of pure milk is allowed to stand until the cream 
has risen. The latter is removed, and to the blue milk thus obtained, 
about a square inch of rennet is to be added, and the milk vessel placed 
in warm water. In about five minutes the curd will have separated, 
and the rennet, which may again be repeatedly used, being removed, 
the whey is carefully poured off, and immediately heated to boiling, to 
prevent its becoming sour. A further quantity of curd separates, and 
must be removed by straining through calico. In one-quarter of a pint 
of this hot whey is to be dissolved three-eighths of an ounce of milk 
sugar ; and this solution, along with the cream removed from the one- 
third of a pint of milk, must be added to half a pint of new milk. This 
will constitute the food for an infant of from five to eight months old 
for twelve hours; or, more correctly speaking, it will be one-half of the 
quantity required for twenty-four hours. It is absolutely necessary 
that a fresh quantity should be prepared every twelve hours ; and it is 
scarcely necessary to add that the strictest cleanliness in all the vessels 
used is indispensable." 

The second method is that by Mr. Lobb: — 

"Haifa pint of new milk is set aside for the cream to separate, which 
latter is removed; and to the blue milk half a teaspoonful of prepared 
rennet is added; this is placed over the fire and heated until the curd 
has separated, when it is broken up with a spoon, and the whey poured 
off. In winter, three drachms of powdered sugar of milk are added to 
this warm whey; and the whole is mixed with half a pint of new milk. 
In summer, three drachms and a half of sugar of milk are added, and 
with the new milk are all boiled together," 



716 APPENDIX. 

I have had no experience in the use of milk prepared by either of 
these two methods. An objection to the latter process is the boiling, 
which is believed to impair the quality of milk. 

The above formulae are designed especially for infants who have not 
reached the age at which it is proper to give farinaceous food. They 
may also be employed for older infants who are in a state of feebleness, 
and whose digestive organs are capable of assimilating only the blandest 
preparations of food. 

Meigs, in his treatise on diseases of children (page 267), recommends 
an article of diet which he states agrees better with the digestive system 
of the infant than any other kind of food which he has emplo}'ed. The 
mode of preparation and the proportions are as follows: "A scruple of 
gelatine (or a piece two inches square of the flat cake in which it is sold) 
is soaked for a short time in cold water, and then boiled in a half a pint 
of water, until it dissolves, about ten or fifteen minutes. To this is 
added, with constant stirring, and just at the termination of the boiling, 
the milk and arrowroot, the latter being previously mixed into a paste 
with a little cold water. After the addition of the milk and arrowroot, 
and just before the removal from the fire, the cream is poured in, and a 
moderate quantity of loaf sugar added. The proportions of milk, 
cream, and arrowroot must depend on the age and digestive powers of 
the child. For a healthy infant, within the month, I usually direct from 
three to four ounces of milk, half an ounce to an ounce of cream and a 
teaspoonful of arrowroot, to half a pint of water. For older children 
the quantity of milk and cream should be gradually increased to a half 
or two-thirds milk, and from one to two ounces of cream. I seldom 
increase the quantity of gelatine or arrowroot." 

Baron Liebig has also recommended a soup for infants which he 
believes to be the best substitute for human milk. By the mode of 
preparation starch is transformed into sugar and dextrin, a change 
which, when farinaceous substances are used in the usual way, is effected 
in the stomach, and thus this organ is relieved from a part of the burden 
of digestion. 

" The following is the best way of preparing this food: Half an ounce 
of wheaten flour, and an equal quantity of malt flour, seven grains and 
a quarter of bicarbonate of potash, and one ounce of water are to be 
well mixed; five ounces of cow's milk are then to be added, and the 
whole put on a gentle fire. When the mixture begins to thicken, it is 
removed from the fire; stirred during five minutes ; heated and stirred 
again, till it becomes quite fluid, and finally made to boil. After the 
separation of the bran by a sieve, it is ready for use. By boiling it for 
a few minutes, it loses all taste of the flour." — (Lancet, January 7th, 
1865; Braithw aite's Betros.,Jn\y, 1865.) 

Liebig has succeeded in preparing an article the ingredients of which, 



APPENDIX. 717 

and their relative proportion, are very similar to those of human milk. 
It has, however, twice the consistence of milk, or, as Liebig expresses 
it, is "the double concentration" of that secretion. 

Dr. Hassell, in a communication in reference to this food to the 
London Lancet for July 29th, 1865, says: "It appears to me that the 
great merit of Liebig's preparation consists in the use of malt flour as a 
constituent of the food; this, from the diastase contained in it, exercises, 
when the fluid food or soup is properly prepared, a most remarkable 
influence upon the starch, quickly transforming it into dextrin and 
sugar, so that in the course of a few minutes the food, from being thick 
and sugarless, becomes comparatively thin and sweet." 

"Correct and ingenious as are the 

principles upon which this food has been designed, yet the directions 
given for its preparation are certainly open to considerable improve- 
ment. Thus, Liebig directs that the malt should be ground in a 
common coffee mill, and the coarse powder passed through a sieve. 
This necessitates the subsequent straining of the food, a tedious opera- 
tion, in order to remove the bran and remaining particles of husk. 
And further, that the food should be put upon a gentle fire previous 
to its being finally boiled. Now, a gentle heat may mean almost any 
temperature nearly up to the boiling point ; and since the action of the 
diastase is destroyed at about 150° F., the temperature should never be 
allowed to exceed that degree. 

"I recommend, therefore, that the malt should be well freed from 
husk, and finely ground; that the wheat flour should be lightly baked; 
and finally, that a thermometer should be employed in the preparation 
of the food. Indeed, in some samples recently submitted to me by 
Messrs. Savorj^ & Moore, I find that the first two points have been 
attended to, and that they use malt freed from husk and finely ground, 
and the wheat flour baked. 

"The effect of baking 'the wheat flour is to partially cook the starch 
entering into its composition, so that less heat is required in the pre- 
paration of the liquid food. I find that a temperature ranging between 
140° and 148° is amply sufficient to effect the complete transformation 
and solution of the starch corpuscles, and, indeed, to cook the food 
sufficiently." 

I have, in some cases, directed food to be given prepared as recom- 
mended by Dr. Meigs, but my observations in reference to the effect of 
it have not been sufficient to enable me to speak confidently in regard 
to it. Gelatine is of little value as a nutritive substance, but it is the 
opinion of some that, when combined with farinaceous substances, it 
renders them less irritating. 

Liebig's soup was prepared a few times for the foundlings in the 
Infant's Service in Charity Hospital. The result did not justify the 



718 APPENDIX. 

expectations which had been formed in consequence of the plausibility 
of the theory, and the reputation of the great chemist. On the first 
day in which it was used, an unusually large number of the foundlings 
were observed to vomit. The soup was prepared under the supervision 
of the matron of the institution. The test was not conclusive, as it is 
probable that there was some fault in the preparation, or in the materials 
used. The mode of preparing this soup is too tedious for common use, 
but it deserves trial in cases in which the ordinary kinds of food 
disagree. 

I have collected the above formulae on account of the great import- 
ance of the use of properly-prepared and digestible food in the regimen 
of infants, especially those that present symptoms of indigestion. 
Success in the treatment of diarrhceal affections, and of all infantile 
diseases which are attended by feebleness of the digestive functions, 
depends as much on dietetic as therapeutic measures. The physician 
should, therefore, be as familiar with dietetic as he is with medicinal 
formulae, that he may use them as occasions arise. 

The egg bears considerable resemblance to milk and to flesh, in its 
chemical composition, and it is often relished by infants and children. 
It is useful in states of feebleness, on account of its highly nutritive 
properties ; and, if given nearly raw, it is easily digested. It should 
not be heated above 130° Fahr., for a higher temperature coagulates 
the albumen. It may be prepared by being placed in boiling water for 
two minutes. This will warm it sufficiently, while only a little of the 
exterior of the albumen is coagulated. 

It remains to speak of meat and the meat-broths. Raw meat was 
first employed by Professor Weisse, of St. Petersburg, in the treatment 
of infantile diarrhoea, consequent on weaning. The lean of beef or 
mutton should be used, and the finely-divided portions removed by 
scraping, given to an infant from eight to twelve months old in quantity 
varying from one to two teaspoonfuls, three or four times in twenty- 
four hours. A larger amount may be given, if the infant wishes it. 
Raw meat prepared in this manner, or veiy finely cut, is not only very 
nutritious, but it sometimes agrees better with the digestive organs of 
the infant, than any of the preparations of milk. 

The use of the pulp of raw meat was introduced into the Children's 
Wards of Philadelphia Hospital in 1855, by Dr. Caspar Lewis. It was 
seasoned with salt, and sometimes sugar was added, to render it more 
palatable. A teaspoonful was at first allowed three or four times daily, 
and the quantity was gradually increased. Infants who were suffering 
from mal-nutrition, were found to thrive with the use of this food as a 
part of their daily diet. The pulp of raw meat has been most frequently 
employed in private as well as hospital practice, in the treatment of the 
indigestion and diarrhoea of infants. Many infants reduced to a state 



APPENDIX. 719 

of feebleness and emaciation gradually recover flesh and strength with 
the use of this diet, which is more easily digested, while it is more 
nutritious, than farinaceous substances or cow's milk. The only danger 
in the use of raw meat is that of producing trichinosis. With care, 
however, in selecting the meat, clanger from this source is slight, as 
trichinosis is a comparatively rare disease. The late Professor Elliott, 
of Bellevue Hospital Medical College, never failed to recommend, in his 
lectures, the use of raw meat for infants wasted with chronic diseases, 
and whose digestive organs were enfeebled. 

Beef-tea, prepared in the ordinary manner, by adding finely-divided 
meat to three or four times its bulk of cold water, allowing it to 
macerate half an hour, and then boiling it fifteen or twenty minutes, is 
much used for its highly nutritive properties in infantile diseases, as 
well as a food for healthy infants. Given, however, in diarrhceal affec- 
tions of infants, I have often observed that it produced a laxative effect, 
so that it was necessary to discontinue its use. The same effect, though 
in less degree, sometimes occurs from the use of mutton or chicken-tea, 
in similar cases. Beef-essence prepared from finely-chopped beef, placed 
dry in a loosely-corked bottle, and standing three or four hours in 
boiling water, is a highly nutritive substance. It is the juice of the 
meat containing all those principles which heat can extract. It is often 
useful, given in small quantities, in exhausting diseases, especially in 
those in which the stomach is irritable, and more bulky food is rejected. 
Evidently, the albumen of the meat is coagulated by the heat, and, 
therefore, lost. 

Liebig's beef-tea is too expensive for common use, but it is a more 
nutritious and better preparation than the beef-essence. It is prepared 
as follows : Finely-divided beef is lixiviated with cold water, so as to 
remove from it all soluble substances. The solution is evaporated to 
dryness over a sand bath, at a temperature of about 120°. At so low a 
temperature neither the albumen nor the coloring matter is coagulated. 
The tea, which contains, unchanged, nearly all the nutritive principles 
of beef, together with the salts, may be diluted with water at the time 
of its use. 

Beef-tea which has been subjected to the action of gastric juice has 
also been recommended. The mucous membrane of the stomach of 
some animal is macerated in water, to which a little hydrochloric acid 
is added in the proportion of three drops of the strong acid to one 
ounce of water. The maceration, which should be at a temperature of 
about *T0° Fahr., produces a liquid having the solvent properties of 
gastric juice. Beef-tea is prepared according to Liebig's formula, and 
then diluted with cold water. This solution should remain a few hours 
cold, and then the artificial gastric juice be added. The fibrin and 
albuminous substances are digested. The product which results has 



720 APPENDIX. 

been called artificial chyme. In cases of deficient gastric juice, or feeble 
digestive power of the stomach, it is obvious that this food may possess 
decided advantages. 

Dr. Routli speaks of Hogarth's Essence of Meat, which is little 
known in this country {Infant Feeding, page 303). "Of the composi- 
tion," says he, "of this material I can say nothing, except that I believe 
it is a concentrated solution of meat tea — in fact, a meat tea reduced 
by the evaporation of its watery ingredients to the consistence of a 
syrup. I can, however, confidently speak from experience of its utility. 
It is certain that children who have been reduced to a state of great 
weakness by hand-feeding, or improper diet, occasionally recover, and 
that almost marvellously, under its influence. I have used principally 
the essence of beef. Its taste is much liked ; and in doses of five or six 
teaspoonfuls daily, with a very little water, it is well digested by children. 
Indeed, it is often borne in infants affected with exhaustive diarrhoea 
from weaning, when milk and farinaceous food disagree." 

Meat teas and essences, which require so much care and time in their 
preparation as those of Liebig and Hogarth, are obviously to be 
employed only in those cases in which there is disease or derangement 
of the digestive organs, or feebleness of the digestive function, so that 
the ordinary kinds of food disagree. Most infants in good health are 
able to digest at the age of twelve or fifteen months, when the period of 
weaning arrives, those kinds of solid food which are easily digested, if 
well prepared and mashed or cut fine. 

As regards the use of farinaceous food for infants and young children, 
barley flour properly boiled in milk or water is as easily digested and 
as nutritious as rice, or wheat flour, or arrowroot, and in some instances 
it appears to agree better. 

An article of food employed in this city for the diarrhoea of infants is 
prepared as follows : A pound of dry wheat flour, of the best quality, is 
packed snugly in a bag and boiled three or four hours. When it is 
taken from the bag, it is hard, resembling a piece of chalk, with the ex- 
ception of the exterior, which is wet and should be removed. The flour 
grated from the mass should be used the same as arrowroot or rice. 



B. 

EEMAEKS ON THE PREVENTION OF SCARLET FEVER. 

By Wm. Budd, M.D., 

Honorary and Consulting Physician to the Bristol Royal Infirmary. 

Much more, indeed, can be done to limit the spread of this malignant 
fever than the public are at all aware of, or than the common practice 
of medical men generally would seem to indicate. 



APPENDIX. 721 

There is good reason to believe that not only the eruption on the 
skin, but everything that is shed by the body of the infected, is heavily 
laden with the germs or seeds by which (alone, no doubt) the disease is 
propagated. The discharges from the throat and nose are, I imagine, 
especially virulent. It is more than suspected, on grounds on which I 
need not here insist, that those from the bowel are scarcely less so. As 
the kidney is known to be affected in a very special, and often in a very 
severe way, by the poison, this organ probably furnishes another outlet 
for it. All analogy tends to indicate, indeed, that in this case the renal 
epithelium, which is cast off so plentifully, performs the same elimina- 
tive function as that which is cast off in still greater profusion by the 
outer surface of the body. As the bulk of all these excreta soon finds 
its way to the cesspool or sewer, the large part which sewers and cess- 
pools are known to play in the dissemination of the fever, and which, 
quite lately even, has been so strangely misinterpreted, is easily under- 
stood. I could enlarge much on this topic, if I had time to do so. It 
must suffice for the present to say, once for all, that all that has been 
shown to hold of typhoid fever in regard to these relations — contamina- 
tion of drinking water included — may be applied, with little qualification, 
to scarlet fever also. 

Taking these things as our data, the one thing to aim at, therefore, 
in seeking to prevent the spread of this fever, is to annihilate the germs 
proceeding from these various sources on their very issue from the 
body, and before the patient leaves the sick-room. In accordance with 
this view, I have long been in the habit, in all cases which fall under 
my own care, of enforcing the following simple precautions : — 

L The room in which the patient is detained is dismantled of all 
needless woollen or other draperies which might possibly serve to harbor 
the poison. 

2. A basin, charged with chloride or carbonate of lime, or some other 
convenient disinfectant, is kept constantly on the bed, for the patient 
to spit into. 

3. A large vessel, containing water impregnated with chlorides or 
with Condy's fluid, always stands in the room, for the reception of all 
bed and body linen, immediately on its removal from the person of the 
patient. 

4. Pocket-handkerchiefs are proscribed ; and small pieces of rag are 
used instead, for wiping the mouth and nose. Each piece, after being 
once used, is immediately burnt. 

5. As the hands of nurses and of the medical attendant of necessity 
become frequently soiled by the specific excreta, a good supply of 
towels, and two basins, one containing water with Condy's fluid or 
chlorides, and another plain soap and. water, are alwa} T s at hand, for the 
immediate removal of the taint. 

46 



722 APPENDIX. 

6. All glasses, cups, or other vessels, used by or about the patient, are 
scrupulously cleaned before being used by others. 

T. The discharges from the bowel and kidney are received, on their 
very issue from the body, into vessels charged with disinfectants. 

By these measures, the greater part of the germs which are thrown 
off by internal surfaces are robbed of their power to propagate the 
fever. Those which are thrown off by the skin require somewhat 
different management. If my information do not mislead me, it is in 
dealing with these that the practice of medical men generally is most 
defective. There are, no doubt, distinguished exceptions ; but for the 
most part, either nothing is done, or what is done is done imperfectly 
or too late. And yet to destroy from the first, as far as possible, the 
infectious power of what emanates from the skin, is, for obvious reasons, 
the most important object of all in the way of prevention. 

In the first place, as the skin is at once the most extensive surface of 
the body, and is, par excellence, the seat of what, by a very just figure, 
is called the eruption, the crop of new poison which escapes by the skin 
probably far exceeds in amount that which escapes by the other surfaces. 
It is impossible to speak in exact figures here. We cannot count these 
things as we count peas, or beans, or grains of wheat. But the care of 
smallpox furnishes us with a standard which cannot far mislead us. 
And, as we know that, in a case of confluent smallpox, enough new 
poison is thrown off actually to inoculate with smallpox myriads of 
others, so there is every reason to believe that the skin- crop in a severe 
case of scarlet fever is little, if at all, less prolific. 

In the next place, as the process of desquamation, by which this crop 
is finally cast loose, is a very slow one — lasting, for the most part, over 
many weeks — the infection from this source is much more abiding than 
that from the internal sources. But what renders it still more so is the 
all-important fact that the poison which is liberated by the skin is 
liberated in the dried state. It is well known — and, indeed, the circum- 
stance has been taken advantage of in the practice of inoculation by 
cowpox and other poisons — that animal poisons, when dried at a gentle 
heat, retain their powers for quite indefinite periods of time. But to 
be dried at a gentle heat — a heat lower in fact than that which attended 
its own generation — is precisely the case of the scarlet fever poison, as 
cast off by the skin. 

Another danger is created by the minute and impalpable form in 
which the particles armed with the poison are set free. The skin peels 
off in part, no doubt, in flakes of palpable size, but in still greater part, 
under the guise of dust, which floats in the air, impalpable like motes in 
the sunbeam. Each of these little atoms is, potentiall}', the scarlet fever. 
While they adhere to the body, they may be readily disarmed; but once 
afloat, they are in great degree beyond our power. 



APPENDIX. 723 

It is to these various circumstances — to the countless profusion of 
the new seed, if I may so speak, which is generated and sown broadcast 
by every fresh case — to the length of time during which it hangs about 
the sick, capable every moment of being transferred, with all its deadly 
power, to thing or person — to the impalpable minuteness of the organic 
particles in whicli this seed is imbedded — and, lastly, to the long reten- 
tion of their properties, in virtue of being in the dried state — that we 
must look mainly for the true explanation of the well-known subtleness 
and tenacity of this particular infection. To the many striking illus- 
trations of this subtlety and tenacity on record, I could, if there were 
need, add many of my own, quite as striking, and free from all 
ambiguity; but it is a waste of time and space to burden the page with 
what is already conceded, and with what most men must be sufficiently 
familiar. 

These same circumstances are the source of the peculiar embarrass- 
ment and perplexity, which, in scarlet fever, hang over the disposal of 
the convalescent, and the period, so much debated, and at present con- 
fessedly undetermined, at which he may be safely restored to society. 

According to my own experience, these difficulties and perplexities 
may be entirely averted by the employment of the simplest precautions. 
To be successful, these precautions must be put in force early, and must- 
be thoroughly carried out. The first thing to aim at, is, to prevent the 
minute particles, which are the carriers of the poison, from taking wing, 
until they can be disenfected in situ. This, I find, can be perfectly 
effected by simply anointing the surface of the body, scalp included, 
twice a day with olive oil. The oil I use is, generally, slightly impreg- 
nated with camphor. As far as the main object is concerned, the 
addition is perhaps unimportant; but it is agreeable to the patient, and 
probably has some part in the relief, which almost always follows the 
inunction, from the troublesome itching, which is a well-known incident 
of some stages of the disorder. Current views would, perhaps, indicate 
carbolic acid as a fitter adjunct ; but, having found the camphorated oil 
to answer perfectly, I have thought it the part of wisdom to make no 
change. I ma}' add, that the process, so far from being trying, is very 
soothing to the sick; and. if it exert any influence at all on the evolu- 
tion of the disorder, this influence appears to be beneficial rather than 
otherwise. The precise period at which it should be begun varies 
somewhat, no doubt, in different cases. As early as the fourth day of 
the eruption, a white efflorescence may often be observed on the skin of 
the neck and arms, which marks the first liberation of the new death- 
giving brood. This efflorescence should be made the signal for the first 
employment of the oil. From this time, the oiling is continued until 
the patient is well enough to take a warm bath, in which the whole 
person — scalp again included — is well scrubbed, disinfecting soap being 



724 APPENDIX. 

abundantly used during the process. These baths are repeated every 
other day, until four have been taken, when, as far as the skin is con- 
cerned, the disinfection may be regarded as complete. If the health be 
quite recovered — if, in particular, there be no disease of kidney and no 
discharge from throat or nostril — the patient (equipped, of course, in a 
new or perfectly untainted suit) may generally be restored without risk 
to his famiPy. A week or ten days' additional quarantine is, however, 
seldom objected to; and is, on the whole, perhaps more prudent. Many 
medical men are in the habit of fumigating the sick-room, either con- 
stantly or several times a daj r , with chlorine or sulphurous acid, pending 
the whole course of the fever. There can be no objection to this 
measure; but I do not myself attach much importance to it. Experience 
of the largest and most decisive kind has shown that chlorine — and I 
believe the observation applies equally to the other chemical agent — in 
the degree of atmospheric impregnation respirable by man, has no 
appreciable influence in preventing the spread of infectious disorders. 
To complete the preventive code, immediately after the illness is over — 
whether ending in death or recovery — the dresses worn by the nurses 
(which, where possible, should be of linen, or some smooth thing) are 
washed or destroyed, and the bed and room that have been occupied b}^ 
the sick are thoroughly disinfected. With these measures, when well 
and thoroughly done, the taint is finally extinguished. The success of 
this method, in my own hands,- has been very remarkable. For a period 
of nearly twenty years, during which I have employed it in a very wide 
field, I have never known the disease to spread in a single instance 
beyond the sick-room, and in very few instances within it. Time after 
time I have treated this fever in houses crowded from attic to base- 
ment, with children and others, who have nevertheless escaped infection. 
The two elements in the method are, separation on the one hand, and 
disinfection on the other. {British Medical Journal, Jan. 9th, 1869.) 

The Health Board of New York enforce the following Sanitary 
Regulations against Scarlatina and Measles : — 

Every case must be reported to the City Sanitary Inspector upon its 
first recognized appearance. 

Care of Patients. — The patient should be placed in a separate room, 
and no person except the physician, nurse, or mother, allowed to enter 
the room, or to touch the bedding or clothing used in the sick-room, 
until they have been thoroughly disinfected. 

Infected Articles. — All clothing, bedding, or other articles not 
absolutely necessary for the use of the patient, should be removed from 
the sick-room. Articles used about the patient, such as sheets, pillow 
cases, blankets, or clothes, must not be removed from the sick-room 
until the}? - have been disinfected, by placing them in a tub with the 
following disinfecting fluid : eight ounces of sulphate of zinc, one ounce 
of carbolic acid, three gallons of water. 



APPENDIX. 725 

The3 T should be soaked in this fluid for at least one hour, and then 
placed in boiling water for washing. 

A piece of muslin, one foot square, should be dipped in the same 
solution and suspended in the sick-room constantly, and the same should 
be done in the hallway adjoining the sick-room. 

Feather beds and pillows, hair pillows and mattresses, and flannels or 
woollen goods, require fumigation, and should not be removed from the 
sick-room until after this has been done. Whenever the patient is 
removed from the sick-room, notify the Bureau of Sanitary Inspection, 
when the disinfecting corps will as soon as possible thereafter perform 
the work of fumigation. 

All vessels used for receiving the discharges of patients should have 
some of the same disinfecting fluid constantly therein, and immediately 
after use by the patient be emptied and cleansed with boiling water. 
Water closets and privies should also be disinfected daily with the same 
fluid, or a solution of chloride of. iron, one pound to a gallon of water, 
adding one or two ounces of carbolic acid. 

All straw beds should be burned, but must not be removed from the 
sick-room without a permit from this department. They will be removed 
by the disinfecting corps. 

It is advised not to use handkerchiefs about the patient, but rather 
soft rags for cleansing the nostrils and mouth, which should be imme- 
diately thereafter burned. 

The ceilings and side walls of the sick-room after removal of the 
patient should be thoroughly cleaned and lime washed, and the wood- 
work and floor thorougly scrubbed with soap and water. 



C. 

REMARKS ON THE DIPHTHERITIC MEMBRANE. 

By Dr. Edward Rindfleisch, 
Professor of Pathological Anatomy in Bonn. 

Genuine diphtheritis has no claim to be regarded as a specific process 
in the same measure as croup. That which microscopically characterizes 
it, and has become the occasion of placing it as a membranous inflam- 
mation by the side of the pseudo-membranous inflammation, is the 
formation of a whitish-gray, often discolored by reddish and green 
(blood-coloring matter) tints, compact, felted membrane, which is ele- 
vated, perhaps, to the height of one-half line alone the level of the 
mucous membrane, but penetrates just as deep into the substance of 
the mucous membrane, and is most intimately connected with the latter. 
This membrane is nothing that is superimposed, nothing secreted, but 



726 APPENDIX. 

the mucosa itself, as far as it has been partly tumefied, partly rendered 
anaemic, even by the excessive infiltration with cells. This condition 
has not improperly been compared with a mortification by a chemical 
agent, with a corrosion, and the diphtheritic membrane has been desig- 
nated as diphtheritic scab ; in fact the diphtheritic membrane is a caput 
mortuum, it can undergo no other changes than those of putrefaction, 
of decomposition; and the question only is, how it is loosened and 
removed from the intimate organic connection in which it stands with 
the mucous membrane. A sharply defined boundary line separates, as 
we can convince ourselves with the naked eye, the living from the dead ; 
but numerous connective-tissue fibres, bloodvessels, nerves, and elastic 
fibres, pass over from the living into the dead ; they must all have 
separated ere the loosening can proceed. The means which are placed 
at the command of the organism are inflammation and suppuration. 
We call this inflammation " reactive," and unite with it the idea as 
though this were an answer to the irritation, which the diphtheritic scab 
exerts upon the surrounding mucous membrane; yet a portion of the 
hyperemia also may be explained according to static principles as 
collateral fluxion. The pus collects between the scab and the healthy 
parts and always, accordingly as the fibrous bridges mentioned melt 
down and tear, the separation begins now at the edges, then at the 
centre. After it is completed an ulcer remains behind which is disposed 
to rapid cicatrization ; not unfrequently, however, the prdcess repeats 
itself again at the same place ; we have a new scab, and with it anew 
the necessity of a purulent separation, after whose termination a very 
considerable loss of substance remains. The cicatrices finally resulting 
distinguish themselves by their capacity of vigorous retraction, so that 
the danger of subsequent contraction of mucous membrane canals, 
especially of the large intestine after dysentery, threatens so much the 
more, the more diffused the ulceration was. (Text-book of Pathological 
Histology, translated, page 354.) 



E. 

The following observations relate to the state of the liver in that 
form of infantile entero-colitis which prevails in the summer months, 
especially in the cities. They were made in order to determine the 
correctness or falsity of a pretty general belief on the part of city 
practitioners, arising probably from the frequent green appearance of 
the stools, that the function of the liver is perverted, and the bile there- 
fore unhealthy, in this disease. These observations are sufficiently 
numerous, in my opinion, to prove that mercurial or other treatment 



APPENDIX. 727 

designed to modify or correct the function of this organ is not justified 
by the anatomical characters of the disease. 

June 8, 1859. Aged 5 months; duration of sickness, 6 days. Liver appeared 
healthy ; about the usual size. 

June 8, 1859. Aged 3 months; duration of sickness, 20 days. Liver of usual 
size and color ; it contained the usual amount of oil globules ; from one to six or 
eight globules in each hepatic cell. 

June 10, 1859. Aged 4 months ; duration of sickness, 5 days. Liver of ordinary 
appearance ; contains rather less fatty matter than usual ; few hepatic cells con- 
tained more than five or six oil globules. 

July 4, 1859. Aged 7 months; duration of sickness, 3 weeks. Liver of yellower 
hue than natural ; not enlarged ; the oil globules considerably exceeded the usual 
amount. 

July 16, 1859. Aged 9 weeks ; duration of sickness, 3 weeks. Liver small and 
almost destitute of oil globules ; nine-tenths of the hepatic cells contained none. 

August 8, 1859. Aged 7 months ; duration of sickness, 1 month. Liver appeared 
healthy ; weighing oz. iv. 

August 15, 1859. Aged 19 months ; duration of sickness, several weeks. Liver 
extended half an inch below the margin of the ribs ; weighed oz. ix ; but few oil 
globules in most of the hepatic cells ; a few contained numerous small globules. 

August 15, 1859. Aged 15 months ; duration of sickness, 2 months. Liver of 
usual appearance ; weight, oz. vijss ; nothing unusual observed in this organ under 
the microscope. 

August 15, 1859. Aged 14 months ; duration of sickness, 3 weeks. Liver 
weighed oz. ix ; its appearance natural both to the naked eye, and under the 
microscope. 

August 17, 1859. Aged 15 months; duration of sickness, several weeks. Liver 
appeared healthy ; weight, oz. vj. 

August 22, 1859. Liver of normal appearance ; it contained the usual amount 
of oil globules; weight, oz. viij. 

August 27, 1859. Aged 9 months. Liver of natural color generally, but yellow 
in places ; weight, oz. viij ; no more than the usual amount of fatty matter dis- 
covered by the microscope. 

August 31, 1859. Aged 5 months ; duration of sickness, at least one month. 
Surface of liver mottled of a yellow color ; no excess of oil globules generally ;. 
weight of liver, oz. vjss. 

September 4, 1859. Aged 2 months ; duration of sickness, one week. Liver of 
normal appearance ; few hepatic cells contained more than four oil globules and 
many contained none ; little free oily matter. 

September 5, 1859. Age 16 months. Liver small ; weighing oz. vj, and con- 
taining very little oily matter. 

September 15, 1859. Aged 23 months ; duration of sickness, all summer. Liver 
quite fatty ; weighing oz. xv ; had tuberculosis. 

July 3, 1860. Aged 13 months ; duration of sickness, nearly one month. Liver 
of yellow color ; weight, oz. vj ; hepatic cells contained somewhat more than the 
usual oily matter. 

July 3, 1860. Aged 4 weeks. Liver extended two inches below the ribs ; weight, 
oz. v ; contained few oil globules. 

August 4, 1860. Duration of sickness, 2 weeks. Liver weighed oz. ix ; 
mottled 3 r ellow ; very fatty. 

August 7, 1860. Aged 2 months ; duration of sickness, 10 days. Anterior bor- 
der of liver even with the margin of the ribs; weight, oz. iijss; usual color; very 
few oil globules, free or in the hepatic cells. 

August 8, 1860. Aged 2 years. Liver mottled with yellow, evidently fatty spots 
or patches. 

August 17, 1860. Liver extended half an inch below the lower margin of the 
ribs ; of usual color ; weight, oz. v. 

August 30, 1860. Aged 5 months ; duration of sickness, 1 week. Liver 
extended half an inch below the margin of the ribs ; rather yellow ; weight, oz. ix ; 
numerous oil globules, both free and in the hepatic cells. 

July 18, 1861. Liver about the usual size and appearance, except that the color 
is lighter in some places than in others. 

August 1, 1861. Aged 2 months ; duration of sickness, about 1 week. Liver 
small and very dark ; the microscope showed it to be almost destitute of oily matter. 



728 APPENDIX. 

August 12, 1861. Aged 3| months. Anterior margin of liver even with the 
ribs ; weight, oz. vss. 

August 19, 1861. Aged 15 months. Weight of liver, oz. ixss ; contained the 
normal amount of fat. 

August 21, 1861. Aged a few months. Liver of usual appearance ; weight oz, 
iijss. 

October 9, 1861. Aged 20 months ; duration of sickness, all summer. Liver 
rather yellow, but not uniformly ; weight, oz. ix ; some hepatic cells free from fat ; 
others loaded with it. 

July 7, 1862. Aged 4 months; duration of sickness, several weeks. Weight of 
liver, oz. v ; yellow, very fatty. 

August 27, 1862. Aged 7 months; duration of sickness, several weeks. Liver 
examined by the microscope seemed healthy ; weight, oz. vi^. 

August 29, 1862. Aged 10 months ; duration of sickness, 1 week. Weight of 
liver, oz. vif ; appeared healthy, except an increase in the amount of oil globules. 



F. 

INTUSSUSCEPTION IN SMALL INTESTINE. 

No. 1. Aged 12 years. Had pain in abdomen two or three weeks previously, 
Died the fifth day. Twelve inches of the upper part of the jejunum invaginated 
in the next twelve inches below. (M. R. Trevor, Amer. Journ. Med. ScL, Jan. 
1852.) 

No. 2. Aged 3 years. Previous health not stated. Died the second day. At 
about the junction of the jejunum and ileum, twenty-six inches of intestine had 
been received into six inches. (Isaac Thomas, M.D., Amer. Med. Recorder, 1823.) 

No. 3. Aged 4| months. Previous health good. Died the fourteenth day. 
Locality of disease, upper part of ileum ; the mass was two-thirds of an inch loDg. 
(Dr. J. L. Smith, Amer. Med. Times, July 18, 1863.) 

No. 4. Aged 4 months. Had entero- colitis previously to and during the intus- 
susception. Four invaginations in the jejunum, each from one to one and a half 
inches in extent. (Records of N. Y. Infant Asylum, July 18, 1863.) 

INTUSSUSCEPTION OF ILEUM INTO COLON. 

No. 5. Age not stated. Had previously constipation, followed by diarrhoea and 
convulsions. Died on the fifth day. Two inches of the ileum projected into the 
coecum. (Dr. Mayne, Path. Soc. Dublin, March 16, 1839.) 

No. 6. Aged 2 years. Previously well. Died the second day. About three 
inches of the ileum inverted had passed through the ileo-ccecal valve into the colon. 
(Dr. Coggswell, Lond. Lane, July, 1853.) 

No. 7. Aged 4 years. Previously well, except slight diarrhoea. Died the tenth 
day. Thirteen inches of the ileum had passed through the ileo-ccecal valve into 
the coecum. (Mr. Filleter, Lond. Lane, May, 1855.) 

No. 8. Aged 3 years. Previous health not given. Died after seven days. At 
least a foot of the ileum had passed through the ileo-ccecal valve. (Mr. Nunnelly, 
Path. Soc. London, March 20, 1860.) 

No. 9. Aged 4 months. Previous health good. Died after six weeks. The 
ileum, still adherent, had passed through the entire colon, so as to protrude six 
inchesebeyond the anus. (S. Jones, Lond. Path. Soc, 1857.) 

No. 10. Aged 6 months. Previously well. Died the third day. The ileum had 
passed through the coecum and into the ascending colon. (Dr. Cotting, Bost. Soc. 
for Med. Improvement, July, 1852.) 

No. 11. Aged 4 years and 9 months. Had a cough, and since the age of eigh- 
teen months, thread Avorms ; was annoyed by these the day before the sickness. 
Died the fifth day. Seven inches of the ileum had passed through the ileo-ccecal 
valve. (Dr. Hare, Lond. Path. Soc, October 16, 1848.) 



APPENDIX. . 729 



INVAGINATION OF THE CCECUM, ILEUM AND C CECUM, OR 
ILEUM, CGECUM, AND COLON. 

No. 12. Aged 5 months. Previous health good. Died the fifth day. Six inches 
of the ileum and the ascending colon were invaginated in the sigmoid flexure and 
rectum. (Thomas Blizard, Med-Chir. Trans., vol. i.) 

No. 13. Aged 4 months. Previous health good. Lived more than one week. 
A small portion of the ileum and the entire colon to the sigmoid flexure, were 
imbedded in the latter. (Alfred Markwick, Lond. Lane, 1846.) 

No. 14. Aged 1 year. Diarrhoea previously. Died on the seventh day. A 
portion of the ileum with the ccecum invaginated in the ascending and transverse 
colon. (Dr. O'Ferrall, Lond. Med. Times, January 16, 1847.) 

No. 15. Aged 6 months. Previous health good. Died the third day. Several 
inches of the ileum, the ccecum, the ascending and the transverse colon, were 
lodged in the remainder of the transverse and in the descending colon. (Chas. 
Clarke, Lond. Lane, August 18, 1849.) 

No. 16. Aged 4 months. Previous health good. Died the third day. Lower 
part of the ileum, the ccecum, ascending colon, and greater part of the transverse 
were imbedded in the descending portion. (E. Y. Steele, Lond. Lane, June 23, 
1849.) 

No. 17. Aged 4 months. Sick two days previously. Died the third day. 
Ccecum and ascending colon invaginated in the transverse and descending colon. 
(P. P. Nind, Lond. Lane, June 23, 1849.) 

No. 18. Aged 20 months. Previous health not stated. Died on the fourth day. 
Six or seven inches of the lower portion of the ileum, the ccecum, and the ascending 
colon were filled with inverted intestine ; the six or seven inches of the ileum were 
drawn together so as to measure only one inch, and this part of the ileum had 
formed a second invagination in the ccecum to the extent of two inches. (Mr. 
Taylor, Lond. Lane, 1843.) 

No. 19. Aged 4 years. Previous health not stated. Lived three days. Lower 
part of the ileum and the entire colon were invaginated in the rectum. (W. S. 
Partridge, Prov. Med. and Surg. Journ., May 3, 1848.) 

No. 20. Aged 5 months. Previous health not stated. About one inch of the 
ileum and the entire colon to the left hypochondrium were lodged in the remaining 
portion of the colon and in the rectum. (R. Harlan, M.D., F.R.S., Med. and 
Phys. Researches.) 

No. 21. Aged 6 years. Diarrhoea and pain in abdomen. The caput coli and 
the first half of the colon had descended through the other half and the rectum ; 
the lower part of the ileum was drawn clown through the centre of the intusus- 
ception to the anus. (Mr. Davis, Med. Repos., December, 1824.) 

No. 22. Aged 9 months. Had occasional diarrhoea. Died the third day. A 
considerable portion of the ileum and the caput coli had been forced up the ascend- 
ing colon, across the transverse and down to the rectum. (H. Cunningham, Lond. 
Med. Gaz., September 15, 1838.) 

No. 23. Aged 4 months. Previous health not given. Died the fourth day. 
Lower portion of the ileum, the ascending colon, and a part of the transverse colon 
were invaginated in the remaining portion of the colon and the rectum. (Alex. 
Munro, Path. Anat, of the Aliment. Canal.) 

No. 24. Aged 4 months. Previous health good. Died the third day. Coecum 
and ascending colon were lodged in the transverse and beginning of the descending 
portions : in the interior of the mass was a second invagination, that of the ileum. 
(Dr. Ryan, Med. Soe of Lond., October 27, 1835.) 

No. 25. Aged 4 months. Previous health good. Died the second day. Part 
of the ileum and ccecum and a considerable portion of the colon were invaginated. 
(Evory Kennedy, Dub. Journ. of Med. Sci., March 1, 1844.) 

No. 26. Aged 7 months. Previous health good. Died the third day. Part of 
the ileum and the coecum had descended through the colon and rectum to within 
half an inch of the anus. (Dr. Buchanan, Lond. Path. Soe. May 3, 1859.) 

No. 27. Aged 6 months. Previous health good. Died the fifth day. A part of 
the ileum and the whole upper portion of the large intestines were inclosed in the 
descending colon and the rectum, to within two inches of the anus. (Mr. Ballard, 
Lond. Path. Soe, January 6, 1857.) 

No. 28. Aged 3 months. Previous health good. Died the third day. Part of 
the ileum and the ascending and transverse colon were lodged in the descending 
colon. (J. W. Perrin, Lancet, March 26, 1853.) 



730 . APPENDIX. 

No. 29. Aged 3 months. Previous health not stated. Died the first day. A 
large part of the ileum, the ascending and transverse colon were invaginated in 
the descending portion. (M. Judson, Gaz. Med., Decembre, 1837.) 

No. 30. Aged 3^ years. Almost constant pain in the bowels for three months 
before death. The coecum and entire colon, to within eleven inches of the anus, 
were invaginated in the remainder of the colon and in the rectum. The inclosed 
intestine protruded five or six inches beyond the anus. (M. Robin, Mem. de 
l'Acad. Roy. de Chirurg., 1784.) 

No. 31. Aged 4 years. Had dysentery previously. Died after sickness of nearly 
a month. The ascending and transverse colon were found in the sigmoid flexure 
and rectum ; the ileum extended uninverted through the whole mass. (John C. 
Lettsom, M.D.,F.R.S.) 

No. 32. Aged 9 months. Previous health delicate, but without disease. Died 
the second day. Six inches of the ileum, the ascending and transverse colon lay 
within the descending colon and the rectum. (Mr. Young, Brit. Med. Journ., 
September 24, 1859.) 

No. 33. Aged 11^ months. Previous health not stated. Died the third day. 
About four inches of the ileum, the ascending and transverse colon, were invagi^ 
nated in the descending colon. (Mr. Clarke, Lond. Lane, February 17, 1838.) 

No. 34. Aged 6 months. Previous health not stated. Died the eighth clay. 
The ccecum, ascending and transverse portions of the colon were invaginated in 
the descending colon. (E. Smith, Lond. Path. Soc, December 4, 1848. 

No. 35. Aged 4 months. Previous health good. Died in nineteen hours. Lower 
portion of the ileum incarcerated in the ascending colon, which was also invaginated 
in the arch. (Mr. Gorham, Guy's Hosp. Reports, October, 1838.) 

No. 36. Aged 3 months and 4 days. Previous health good. Died on the eighth 
day. Twelve inches of the ileum doubled on itself had descended the whole 
length of the colon, so as to protrude from the anus ; colon drawn together, the 
mass occupying less than a foot. (Dr. J. L. Smith, N. Y. Path. Soc, June, 1861.) 

No. 37. Aged 3 years and 4 months. During two years before death complained 
of pain in abdomen. The ccecum was inverted, and had descended to the lower 
portion of the rectum. (Winner Worthington, M.D., Amer. Journ. of Med. Sci., 
January, 1849.) 

No. 38. Aged 10 months. Previous health good, except liability to constipation. 
Lived two days. A double intussusception ; the inferior portion of the ascending 
colon was invaginated in the superior, and the whole again invaginated in the 
transverse colon. (Dr. Blake, Prov. Med. and Surg. Journ., May 3, 1848.) 

No. 39. Aged 11 years. Previous health not stated. Recovered. On the sixth 
day, the caput coli and a portion of the colon, -with the meso-colon, measuring 
thirteen and three-fourths inches, were passed from the bowels. (J. W. Bowman, 
Edin. Med. and Surg. Journ., October, 1813.) 

No. 40. Aged 6 years. Previous health not stated. Recovered. On the 
eleventh day voided the ccecum and a part of the colon. (Chas. King, Lond. Lane, 
1854.) 

No. 41. Aged 4 months. Previous health good. Died the third day. The 
ccecum had descended through the colon, nearly to the rectum. (Dr. Penquier, 
L'Union Medicale, Aug. 22, 1861.) 

No. 42. Aged 5 years. Was ill with fever and pain in region of bladder for four 
months ; date of commencement of intussusception not known. Recovered. Passed 
by stool eight inches of the ileum, the ccecum, and four inches of the colon. (Dr. 
Quain, Lond. Path. Soc, Aug. 16, 1859.) 

No. 43 Age not stated. Previous health good. Died the third day. The upper 
part of the descending colon had descended into the inferior part to the extent of 
two inches. (Dr. Montgomery, Lond. Med. Times, December 23, 1848.) 

No. 44. Aged 6 months. Slight diarrhoea two or three days previously to sick- 
ness. Intussusception in the transverse colon to the extent of two or three inches. 
(E. Y. Steele, Lond. Lane, June 23, 1849.) 

No. 45. Aged 4 months. Had nausea with vomiting for three weeks previously 
to severe symptoms. Died after six days. The lower portion of the colon, and 
the upper part of the rectum, had descended into the portion below. (Mr. Howship, 
Edin. Med. Journ., April, 1812.) 



APPENDIX. 731 



UNCERTAIN. 

No. 46. Aged 4 months. Had disordered bowels from birth. Died on the sixth 
day. An intussusception was found in the left iliac region. (H. F. Carter, Lond. 
Lane, June 2, 1849.) 

No. 47. Aged 6 years. Previous health not stated. Recovered. Twenty-three 
inches of intestine were discharged. (Levi Gaylord, Anier. Journ. of Med. Sci., 
October, 1827.) 

No. 48. Aged 12 years. Previous health not stated. Recovered. Fifteen or 
eighteen inches of ileum were passed by stool. (F. Bush, Lond. Med. and Phys. 
Journ., December 18, 1823.) 

No. 49. Aged 12 years. Had occasional purging and pain in the bowels. 
Recovered. A portion of ileum twelve inches long was passed. (John Lang, 
Lond. Lane, October, 1855.) 

No. 50. Fatal. An invagination of the intestine was found in the rectum. (Dr. 
Jacobi, N. Y. Path. Soc, August 8, 1861.) 

No. 51. Aged 9 years. Had dysentery previously. Recovered. A portion of 
intestine measuring ten inches was passed. (Dr. Patterson, Medico-Chirurg. Soc, 
Edin.) 

No. 52. Aged 8 months. Previous health good. Died the second day. A 
portion of intestine protruded. (E. Y. Steele, Lond. Lane, June 23, 1849.) 



INDEX 



ABDOMINAL viscera, tubercles in, 123 
Abscess, peri-pharyngeal, 559 
Abscess in lungs, 480 
Acarus scabiei, 711 
Accidents, incidental to birth, 62 
Acephalus, 298 

anatomical characters, 298 

symptoms, 299 

prognosis, 299 
Acid, hydrocyanic, in pertussis, 257 
Acne, syphilitic, 153 
Affusions, cold, in scarlet fever, 189 
Allin, Dr., statistics of peri-pharyngeal 

abscess, 559 
Animal heat, 85 
Apnoea of the new-born, 62 

causes, 62 

treatment, 63 
Appendix A., dietetic formula?, 715 
Appendix B., Wm. Budd on prevention 

of scarlet fever, 720 
Appendix C, Prof. Rindfleisch, remarks 

on the diphtheritic membrane, 725 
Appendix E., statistics of state of liver 

in entero-colitis, 726 
Appendix F., statistics of intussuscep- 
tion, 728 
Aqueous cancer of infants, 544 
Armor, Dr., case of taenia, 637 
Arteritis, umbilical, 69 
Artificial feeding, 57 
Ascaris vermicularis, 636 

lurnbricoides, 634 
Asphyxia of the new-born, 62 
Atrophy of brain, 301 
Attitude in disease, 79 



BARKER, Prof. Fordyce, on turpeth 
mineral in croup, 467 
Baths, 60 

Billard, case of tetanus infantum, 383 
cases of gangrene of mouth, 540 
Bouchut's views of scrofula, 116 

on santonin as an anthelmintic, 643 
Bowditch, Dr., mode of performing 
thoracentesis, 522 



Brain, its chemical analysis, 297 
its growth, 297 
absence of, 298 
imperfect, 299 
atrophy, 301 
hypertrophy, 304 
congestion, 314 
Bretonneau, on diphtheria, 238 
Brodie, Sir Benjamin, on chorea, 424 
Bromides in pertussis, 254 
Bronchitis in measles, 163 
Bronchial phthisis, 132 
physical signs, 140 
Bronchitis, 476 
causes, 477 

anatomical characters, 477 
capillary, 478 
complications, 480 
pneumonia, 480 
abscesses, 480 
dilation of bronchial tubes, 481 
symptoms, 481 

in capillary bronchitis, 483 
chronic, 484 
diagnosis, 485 
prognosis, 485 
treatment, 486 
Brown-Sequard, on compression of sym- 
pathetic nerve for eclampsia, 379 
Bruit de soutflet of anterior fontanelle, 

101 
Buchler, Dr., cases of intussusception, 

670 
Bulbous fingers, 78 
Bumstead on syphilis, 151 



CALOMEL, its use in croup, 467 
Cancrum oris, 538 
Caput succedaneum, 64 
Care of mother in pregnancy, 20 
Carswell, Dr., on softening of stomach, 

582 
Castor-oil plant as a galactogogue, 47 
Catamenia, its effect on the milk, 40 
Cavities in lungs, 131 
Cellulitis, scrofulous, 111 



73i 



INDEX 



Cephalhematoma, 64 
Cerebro-spinal system, diseases, 295 
Chenopodium, 644 
Chickenpox, 224 
Childhood, 19 
Cholera infantum, 624 
causes, 625 
symptoms, 625 
anatomical characters, 627 
diagnosis, 630 
prognosis, 630 
treatment, 630 
Chorea major, 421 
Chorea (chorea minor), 415 
age, 416 
causes, 416 
sex, 417 

uterine imitation, 417 
anaemia, 417 
rheumatism, 418 
embolism, 420 
fright, 420 
irritation, 421 
intestinal irritation, 421 
lesions of brain and spinal cord, 
422 
mica 
symptoms, 424 
prognosis, 426 
cause, 426 
treatment, 427 

regimenal, 427 
medicinal, 428 
Church, Dr. A. S., case of tonic con- 
vulsions from dentition, 550 
Cimicifuga in treatment of chorea, 429 
Circulatory system, 82 
Cirrhosis, syphilitic, 154 
Clark, Prof. A., case of syphilis from 

vaccination, 219 
Clarke, Dr. Joseph, on treatment of 

tetanus infantum, 387 
Clothing, 60 
Coates, Dr., treatment of gangrene of 

mouth, 545 
Colitis in childhood, 620 
causes, 620 
symptoms, 621 
diagnosis, 622 
prognosis, 622 
treatment, 622 
Colles, Dr., on tetanus infantum, 388 
Colostrum, 34 

Condie, Dr. D. F., on erysipelas, 289 
on turpentine as an anthelmintic, 645 
erysipelas, 289 
Congestion of brain, 314 
causes, 314 
symptoms, 317 
anatomical characters, 317 
prognosis, 317 
treatment, 318 
Congestion of stomach, 574 
Conjunctivitis of the new-born, 65 
causes, 66 



Conjunctivitis — 

symptoms, 66 

treatment, 67 
Convulsions, 369 

internal, 405 
Coryza, acute and chronic, 445 

anatomical characters, 446 
symptoms, 446 
prognosis, 447 
treatment, 447 

syphilitic, 152 
Cranial sinuses, thrombosis of, 308 
Craniotabes, 96 
Croup, false or spasmodic, 452 

true, or pseudo-membranous, 458 
Cruveilhier, M., on gelatinous softening, 

581 
Cummings, Dr. W. H., on amount of 

milk secreted, 41 
Curvatures in rachitis, 97 
Cyanosis, 674 

literature of, 675 

sex, 678 

causes of malformations, 678 

time of commencement, 680 

symptoms, 681 

prognosis, 686 

mode of death, 687 

modes of compensation, 689 

morbid anatomy, 689 

theories relating to its etiology 691 

treatment, 693 



D ALTON, Prof., effect of maternal 
emotions, 23 
on iodide of starch, 119 
Dartrous diathesis, 707 
Dentition, 546 

physiological, 547 
pathological results of, 548 
gengivitis, 548 
stomatitis, 548 
diarrhoea, 549 
convulsions, 549 
tonic, 550 

case, 550 
paralysis, 550 
diagnosis, 551 
treatment, 551 
second, 554 
in rachitis, 99 
Diagnosis of infantile diseases, 000 
Diarrhoea, 585 

choleriform 624 
non-inflammatory, 585 
causes, 586 
symptoms, 587 
anatomical characters, 588 
diagnosis, 589 
prognosis, 589 
treatment, 590 
Diday, on syphilis, 157 
Diet, improper, a cause of infantile mor- 
tality, 27 



INDEX 



735 



Digestion, post-mortem, 580 
Digestive system, 86 
Diphtheria, 228 

forms, 228 

anatomical characters, 228 

appearance of pseudo-membrane, 229 

confervoid growth on it, 230 

adenitis, cervical, in, 232 

symptoms, 232 

albuminuria in, 235 

nature, 237 

contagiousness, 238 

incubative period, 239 

sequela?, 239 

paralysis, 240 

prognosis, 241 

diagnosis, 242 

treatment, 243 
Diseases of umbilicus, 69 
Donne, Dr., on ascertaining the capa- 
bility for wet-nursing, 29 

discovery of pus in the milk by the 
microscope, 33 
Dysentery, in childhood, 620 
Dyspepsia, 567 



ECLAMPSIA, 369 
causes, 370 

premonitory stage, 371 

symptoms, 372 

anatomical characters, 375 

diagnosis, 376 

prognosis, 377 

treatment, 378 
Ecthyma, 153 
Eczema, 704 

varieties, 704 

diagnosis, 706 

treatment, 707 
general, 708 
local, 709 
Electricity as a galactogogue, 45 
Elliott, Prof. Geo. T., cases of peripha- 
ryngeal abscess, 560, 565 

use of raw meat, 719 
Emotions, effect in pregnancy, 20 
Emphysema in tuberculosis, 131 
Enteritis in childhood, 620 

causes, 620 

symptoms, 621 

diagnosis, 622 

prognosis, 622 

treatment, 622 
Entero-colitis 592 
Erysipelas from vaccination, 218 
Erysipelas, 284 

cases, 285 

age, 286 

point of commencement, 286 

causes, 286 

from vaccination, 287 

during epidemics of puerperal fever, 
288 

symptoms, premonitory, 289 



Erysipelas — 

symptoms, 290 

prognosis, 291 

duration, 291 

modes of death, 292 

pathological anatomy, 292 

treatment, 293 
Erythema, 695 

forms and causes, 695 

prognosis, 697 

diagnosis, 697 

treatment, 697 
Ether, in spasmodic laryngitis, 456 
Evanson and Maunsell, on treatment of 
gangrene of mouth, 545 



FACIAL paralysis, 440 
Falkland's, Prof., preparation of 
milk for infants, 715 
Features in disease, 76 
Feeding, a cause of infantile mortality, 
26 
artificial, 57 
Fever and ague,. 263 

Fleming, Mr., on retro-pharyngeal ab- 
scess, 560 
Flint, Prof. Austin, Jr., on the diet of 

children, 27 
Flint, Prof. Austin, Sen., prevention of 
pitting in smallpox, 211 
on thoracentesis, 521 
Foetus, effect on it of maternal emotions, 

21 
Fox, Tilbury, on seat of strophulus, 703 
Friedleben, Dr., on state of thyroid gland 

in internal convulsions, 406 
Fungus of umbilicus, 71 



GALACTOGOGUES, 45 
electricity, 45 
ricinus communis, 47 
Galactorrhcea, causes, 48 

treatment, 49 
Gangrene in scarlatina, 177 
of the mouth, 538 

anatomical characters, 538 
age, 539 
causes, 540 
symptoms, 540 
diagnosis, 542 
prognosis, 542 
treatment, 544 
Gastric tuberculosis, 133 
Gastritis, 574 

causes, 575 
age, 576 

case, 576 
symptoms, 577 
anatomical characters, 577 
diagnosis, 578 
prognosis, 578 
treatment, 578 
diphtheritic, 579 



736 



INDEX 



Gastritis — 

follicular, 579 
Gastrointestinal hemorrhage, 646 
Gelatinous softening, 580 
Gilnllan, Dr., on use of ricinus communis 

as a galactogogue, 48 
Glottis, spasm of, 405 
Granulations, umbilical, 71 
Grease in the horse, its identity with 

vaccinia, 214 
Guersant, M. , on prognosis in meningitis, 
359 
on thoracentesis, 522 
extent of pseudo-membrane in croup, 
461 



HALL, Marshall, on treatment of in- 
ternal convulsions, 414 
on spurious hydrocephalus, 365 
Hall, Prof., case of unusual lactation, 45 
Hammond, Prof., on maternal emotions, 

22 
Harris, Dr. Elisha, prevention of scarlet 

fever, 200 
Hassel, Dr., on Liebig's soup, 717 
Hawley's pepsin, 573 
Heart, diseases of, 674 
Heimacy, tetanus in, 386 
Helmerich's ointment, 713 
Hemorrhage, intra- cranial, 319 
causes, 319 

anatomical characters, 320 
meningeal, 321 
cerebral, 323 
symptoms, 324 
capillary, 327 
diagnosis, 328 
prognosis, 329 
treatment, 329 
umbilical, 72 
causes, 73 
sex, age, 73 

jaundice in cases of, 74 
symptoms, 75 
prognosis, 75 
treatment, 75 
gastro-intestinal, 646 
first variety, 647 
second variety, 648 
third variety, 649 

case, 648 
prognosis, 650 
treatment, 650 
Hewitt, Dr. Graily, case of post-mortem 

digestion, 567 
Hillier, on choreic heart murmurs, 415 

causes of urticaria, 701 
Hogarth's essence of meat, 720 
Holmes, on scrofulous affections, 113 
Hooping-cough, 247 
Hutchinson, on syphilis, 155 
Hydrocephalus, congenital, 330 

anatomical characters, 331 
case, 334 



Hydrocephalus, congenital — 

symptoms, 334 

diagnosis, 336 

prognosis, 337 

treatment, 337 
acquired, 338 

causes, 338 

anatomical characters, 335 

symptoms, 340 

prognosis, 340 

treatment, 341 
spurious, 363 

anatomical characters, 363 
case, 364 

symptoms, 365 
case, 366, 367 

diagnosis, 368 

prognosis, 368 

treatment, 369 
Hypertrophy of brain, 302 
anatomy, 303 
causes, 304 
symptoms, 305 

case, 306 
diagnosis, 307 
prognosis, 307 
treatment, 307 



T CTERUS of the new-born, 76 
1 Impetigo, syphilitic, 153 
Imperfect brain, 299 

case, 300 

symptoms, 300 

prognosis, 301 
Indigestion, 567 

causes, 568 

symptoms, 569 

prognosis, 571 

treatment, 571 
Infancy, 17 

its anatomical characters, 17 

causes of great mortality in, 18 
Inflammation of stomach, 574 

of umbilicus, 70 
Intermittent fever, 263 

in foetus, 263 

symptoms, 264 

three stages of paroxysms, 264 

congestive or pernicious, 265 

treatment, 266 
Internal convulsions, 405 

causes, 406 

anatomical characters, 408 

symptoms, 409 
case, 410 

diagnosis, 411 

prognosis, 411 

treatment, 412 
Intestines, inflammation of, 592 

invagination of, 652 
Intestinal inflammation, 592 
causes, 594 
age, 598 
symptoms, 599 



IXDEX. 



737 



Intestinal inflammation — 

anatomical characters, 602 
diagnosis, 609 
prognosis, 609 
treatment. 610 

regimenal, 610 
medicinal, 613 
enemata, 616 
external treatment, 619 
Intestinal worms, 633 

ascaris lumbricoides, 634 
vermicularis, 636 
trichocephalus dispar, 636 
taenia, 636 

causes, 637 
symptoms, 639 
diagnosis, 416 
prognosis, 642 
treatment, 643 
Intussusception, 652 

"without symptoms, 652 
with symptoms, 653 
previous health, 653 
causes, 654 
age, 655 

seat and pathological anatomy 
656 
of small intestines, 656 

cases, 657 
in large intestines, 659 
symptoms, 652 
diagnosis, 665 
duration, 665 
prognosis, 666 
mode of death, 668 
treatment, 668 
Iodine in scrofula, 119 



JACKSOlN", Dr. James, on treatment 
of bronchitis, 486 
on second dentition, 554 
treatment of cholera infantum, 631 
Jacobi, Prof. A., on laryngismus, 407 

statistics of croup, 472 
Jaundice in the new-born, 76 
Jenkins, Dr. J. Foster, on umbilical 

hemorrhage, 72 
Jenner, Edward, introduction of vacci- 
nation, 213 
Jenner, Sir Win., heart murmurs in 

chorea, 415 
Jesty, Benjamin, the first vaccinator, 213 



T7ERMES mineral, a cause of gastritis. 
-IV 575 

Kilda, St., tetanus in, 386 
KrackoAvizer, Dr., cases of tracheotomy 
in croup, 472 



Lactation — 

facts and rules in reference to, 33 
Lanugo, 17 

Laiyngitis, simple, acute, 449 
symptoms, 449 
chronic, 450 

anatomical characters, 451 
treatment, 451 
spasmodic, 452 
causes, 452 
symptoms. 452 
anatomical characters, 454 
pathology, 454 
diagnosis, 454 
prognosis, 455 
treatment, 455 
pseudo-membranous, 458 
causes, 459 

anatomical characters, 459 
symptoms, 462 
pathological characters, 464 
diagnosis, 465 
prognosis, 465 
treatment, 466 
tracheotomy, 472 
Learning, Dr. J. R., case of ervsipelas. 

288 
Lewis, Dr. Caspar, use of raw meat, 718 
Liebig's beef-tea, 719 

soup. 716 
i Liver, its state in entero-colitis, 607 
' Livingston, Dr., case of peri-pharyngeal 

abscess, 565 
'■ Lungs, tubercles in, 129 



M 



24 



LACTATION, 28 
course of. 54 
hindrances to, 29 

47 



; Maternal emotions, effect of, in preg- 
nancy, 20 
| Measles, 159 

symptoms, 159 
anomalies, 162 
complications, 163 
anatomical characters, 166 
nature, 166 
diagnosis, 166 
prognosis, 167 
treatment, 167 
Meigs, Dr. J. F.. on chenopodium as an 
anthelmintic, 644 
and Pepper, Drs., treatment of 
chronic coryza, 448 
Meningitis, simple and tubercular, 342 
age, 344 

anatomical characters, 344 
causes 349 

premonitory stage, 349 
symptoms, 350 

case, 355 

diagnosis, 356 

prognosis, 357 

treatment; 359 

Microcephalus. 301 

3Iilk. human. 36 



738 



INDEX 



Milk- 
modifications, from diet, 36 

from retention in breast, 38 
by age and nervous impressions, 

34 
by catamenia and pregnancy, 40 

quantity, required, 41 

scantiness, 43 

examination of, 51 

excess of salines in, 53 

vibriones in, 52 

its composition, 58 

of animals, 58 
Minchin's mode of examining milk, 51 
Minot, Dr. Francis, on umbilical hemor- 
rhage, 72 
Morbilli, 159 
Mortality of early life, 23 

causes, 24-28 
Mother, care of, in pregnancy, 20 

effect of maternal impressions, 21 
Mouth, inflammation of cavity of, 524 
Movements in disease, 79 
Mucuna pruriens as an anthelmiutic, 645 
Muguet, 533 
Mumps, 261 



NECROSIS, infantilis, 538 
Nephritis in scarlatina, 180 
Nervous system, 88 
Nestle 1 s food, 59 
Noma, 538 

Noyes, Prof. H. D., on use of ophthal- 
moscope, 296 



^SOPH^ai'IIS, 566 
anatomical characters, 566 
treatment, 567 
Oidium albicans in sprue, 534 
Ophthalmia neonatorum, 65 
two forms, 67 
symptoms, 66 
treatment, 67 
Ophthalmoscope in diseases of brain, 296 
Osteo-malacia, 92 
Otitis, scrofulous, 112 
■Otorrlicea, 182 



PAIN as a symptom, 88 
Papulae, 702 
Paralysis, diphtheritic, 240 
facial, 440 

causes, 440 
symptoms, 440 
prognosis, 440 
treatment, 441 
Paralysis, infantile, 431 
causes, 431 
symptoms, 432 
prognosis, 433 
progress, 433 
etiology, 434 



Paralysis, infantile- 
anatomical 
diagnosis, 437 
prognosis, 437 
treatment, 438 
Paralysis with apparent hypertrophy, 441 
symptoms, 442 
anatomical characters, 443 
causes, 444 
prognosis, 444 
treatment, 444 
Parker, Dr. E. H., treatment of entero- 
colitis, 613 
lesions of cholera infantum, 629 
Parker, Prof. Willard, case of peri- 
pharyngeal abscess, 564 
Parotiditis, 261 
symptoms, 261 
nature, 262 
diagnosis, 262 
treatment, 262 
Peacock, on growth of brain, 297 
Pemphigus, syphilitic, 153 
Pepsin in indigestion, 573 
Peritoneal tuberculosis, 133 
Peritonitis, tubercular, 133 
Peripharyngeal abscess, 559 
age, 559 
causes, 559 

anatomical characters, 561 
symptoms, 561 

case, 562 
duration, 563 
diagnosis, 564 
prognosis, 565 
treatment, 565 
Pertussis, 247 

symptoms, 247 
three stages, 248 
complications, 250 
convulsions, 250 
bronchitis, 251 
pneumonitis, 251 
emphysema, 252 
diagnosis, 253 
prognosis, 254 
treatment, 255 

belladonna, 256 
hydrocyanic acid, 257 
bromides, 258 
emetics, 259 
Pharyngitis, simple, 555 

anatomical characters, 555 
causes, 556 
symptoms, 556 
prognosis 557 
diagnosis, 557 
treatment, 557 
Phthisis, 122 
Phlebitis, umbilical, 69 
Pleuritis, 507 
causes, 508 
cases, 510, 517 
anatomical characters, 511 
symptoms, 513 



INDEX, 



73y 



Pleuritis — 

physical signs, 514 
diagnosis, 517 
prognosis, 518 
treatment, 519 
thoracentesis, 521 
Pneumonitis, 490 

causes, 491 

anatomical characters, 493 
croupous, 494 
catarrhal, 495 
cheesy, 407 
symptoms, 499 
physical signs, 501 
diagnosis, 502 
prognosis, 504 
treatment, 504 
in measles, 164 
Post-mortem digestion, 580 
Pock, vaccine, its anatomy, 217 
Post, Prof. A., case of peri-pharyngeal 

abscess, 564 
Pregnancy, its effect on the milk, 40 
Protection from vaccination, 221 
Pulmonary cavities, 131 

tuberculosis, 129 
Pulse in health, 82 
in disease, 84 



KACHITIS, 91 
causes, 93 

age, 91 

anatomical characters, 94 

craniotabes, 96 

curvatures, 97 

symptoms, 100 

complications, 102 

diagnosis, 103 

prognosis, 103 

treatment, 104 
Radcliffe, Mr., on treatment of chorea, 

430 
Remittent fever, 267 

symptoms, 268 

diagnosis, 268 

treatment, 268 
Respiration in health, 80 

in disease, 81 
Respiratory system in Children, 80 

diseases of, 445 
Retro-pharyngeal abscess, 559 
Revaccination, 221 
Reynolds, Dr. J. B., case of diphtheria, 

240 
Rheumatism, acute, 277 

its frequency in children, 277 

causes, 278 

symptoms, 278 

complications, 280 

duration, 280 

prognosis, 280 

diagnosis, 281 

treatment, 282 
Ricinus communis, as a galactogogue, 47 



Rickets, 91 

Rokitansky on hypertrophy of brain, 304 

Roseola, 698 

symptoms, 699 

causes, 700 

prognosis, 700 

diagnosis, 700 

treatment, 700 
Routh, Dr., mortality from change of 
temperature, 26 

plethora, a cause of insufficient milk, 
44 
Rubeola, 159 



CCABIES, 711 

U acarus scabiei, 711 

symptoms, 712 

diagnosis, 712 

treatment, 713 
Scantinesss of milk, 43 
Scarlatina, 169 

symptoms, 169 

irregular form, 173 

malignant form, 174 

complications, 175 

sequelae, 178 

nephritis, 182 

otorrhcea, 182 

anatomical characters, 183 

nature, 183 

incubative period, 185 

diagnosis, 187 

prognosis, 188 

treatment, 189 

prophylaxis, 198 
Scrofula, 104 

causes, 105 

vaccination as a cause, 106 

communicability, 106 

anatomical characters, 109 

symptoms, 110 

coryza, 112 

otitis, 112 

cellulitis, 111 

its relation to tuberculosis, 114 

prognosis, 117 

treatment, 118 
Scrofulous affections, 113 
Seguin, Dr., effect of maternal emotions 

on foetus, 23 
Skene, Prof., case of tamia, 637 
Skin diseases, 695 
Smallpox, 201 

Smith, Prof. Stephen, on umbilical hem- 
orrhage, 72 

operation for congenital hydrocepha- 
lus, 336 
Softening, gastro-intestinal, 580 
Spasm of glottis, 405 
Spigelia marilandica, as an anthelmintic, 

643 
Sprue, 535 

Steam, its employment in croup, 469 
Stille, Dr. Moreton, on cyanosis, 677 



'40 



INDEX, 



Stomach, congestion of, 574 
inflammation of, 566 
tubercles in, 133 
Stomatitis, simple, 524 
causes, 524 
symptoms, 526 
appearances, 526 
treatment, 527 
ulcerous, 527 
causes, 528 
symptoms, 557 
prognosis, 529 
treatment, 529 
follicular, 530 
causes, 531 
symptoms, 531 
diagnosis, 532 
prognosis, 532- 
treatment^ 232 
Strabismus, 78 
Strophulus, 702 
varieties, 702 
causes, 703 
treatment, 703 
St.. Guy's dance, 415 
St. Vitus' dance, 415 
Strychnine in treatment of chorea, 428 
Swett, Prof., case of hemorrhage, 649 
Swinepox, 224 
Syphilis, 149 
etiology, 149 
clinical history, 150 
eoryza, 152 
mucous patches, 152 
roseola, 153 
pemphigus, 153 
acne, 153 
impetigo, 153 
ecthyma, 153 
visceral lesions, 154 
prognosis, 156 
treatment, 156 



T^NIA, 636 
Teething, 546 
Temperature, 85 
Tetanus infantum, 382 
cases, 383 

period of commencement, 385 
frequency, 385 
causes, 387 

uncleanliness, 388 
irritation in bowels, 388 
changes of temperature, 389 
inflammation of umbilical ves- 
sels, 390 
meningitis, 393 
injury of brain, 395 
anatomical characters, 396 
symptoms, 398 
mode of death, 400 
prognosis, 400 
duration of fatal cases, 401 
of favorable cases, 402 



Tetanus infantum — 
diagnosis, 402 
preventive treatment, 402 
treatment, 403 
Thorax, shape, in tuberculosis, 142 
Thrombosis in cranial sinuses, 308 
causes, 311 

anatomical characters, 309 
symptoms, 312 
diagnosis, 313 
prognosis, 313 
treatment, 313 
Thrush, 533 

anatomical characters, 533 
symptoms, 535 
causes, 535 
diagnosis, 536 
prognosis, 536 
treatment, 536 
Thymic asthma, 405 
Trismus, 382 

Trousseau, on syphilitic tint, 151 
Tuberculosis, 122 

its relation to scrofula, 115 
etiology, 123 

anatomical characters, 126 
symptoms, 135 
anasarca, 136 
emaciation, 136 
fever, 136 

in bronchial phthisis, 139 
in pulmonary phthisis, 140 
in tubercles of pleura, 143 
in gastric and intestinal tu 
bercles, 144 
diagnosis, 144 
prognosis, 147 
treatment, 148 
Tubercles in lungs, 128 
stomach, 133 
intestines, 133 
bronchial glands, 131 
Typhoid fever, 269 
causes, 269 

anatomical characters, 270 
symptoms, 271 
complications, 273 
diagnosis, 274 
duration, 275 
prognosis, 275 
treatment, 278 



TjLCERATION of umbilicus, 70 
U Umbilicus, diseases, 69 
inflammation of vessels, 69 

of umbilicus, 70 
ulceration of, 70 
treatment, 71 
granulations, 71 
fungus, 71 
hemorrhage, 72 
inflammation of, 284 
Urticaria, 701 
causes, 701 



INDEX. 



'41 



Urticaria — 

prognosis, 701 
diagnosis, 701 
treatment, 702 



y AC CITATIONS, subsequent, 220 
» spurious, 221 
Vaccinia, 212 

history of, 213 

appearance, 216 

symptoms, 216 

anomalies, 217 

complications, 217 

sequels, 217 

subsequent vaccinations, 220 

protection from, 216, 221 

revaccination, 221 

selection of virus, 223 
Varicella, 224 

symptoms of, 224 

diagnosis, 225 

pros'nosis and treatment, 226 
Variola "201 

incubative period, 201 

stage of invasion, 201 
of eruption, 202 
of desiccation, 204 
Varioloid, 205 

mode of death, 206 

anatomical characters, 207 

complications, 208 



Varioloid — 

prognosis, 208 

diagnosis, 209 

treatment, 209 
Vibriones in milk, 52 
Villemin on origin of tubercles, 124 
Virus, vaccine, its selection, 223 
Voice in disease, 79 

Voss, Dr. , cases of tracheotomy in croup, 
472 



WARE, Dr., statistics of croup, 461 
Waxy degeneration in rachitis, 99 
Weaning, 54 

age for, 55 

mode, 56 
West, Dr. Chas., case of thrombosis, 310 

treatment of chorea, 429 

on gelatinous softening, 581 
Wet-nurse, selection of, 49 

syphilis in, 50 
Whitehead, Dr., effect of maternal emo- 
tions on the foetus, 22 
White softening, gastro-intestinal, 580 
White, Prof. J. P., case of cyanosis, 694 
Whytt, Dr., on meningitis, 341 
Worms intestinal, 633 



y IXC, oxide of, in eczema, 710 



THE END 



THOMAS ON DISEASES OF WOMEN.— Now Ready. 



A PRACTICAL TREATISE 



ON THE DISEASES OF WOMEN. 



By T. GAILLAED THOMAS, M.D., 

ics and Diseases of Women and Children in the College of Physicians and 



Professor of Obsteti^ — - 

Surgeons New York; Obstetric Physician to the Strangers' and the Roosevelt Hos- 
pitals ; Consulting Physician to the N. Y. State Women's Hospital, &c. 

With abotit Two Hundred and Fifty Illustrations. 

THIRD EDITION, ENLARGED AND THOROUGHLY REVISED. 

In one large and handsome octavo volume of 784 pages : leather, $6 00 ; cloth, $5 00. 
The exhaustion of two very large editions in a little more than three years shows that the 
author has not failed in his endeavor to supply the admitted want of a work which should, in a 
moderate compass, furnish a complete view of all the modern aspects of gynecology. Stimulated 
by the very favorable reception accorded to his labors, he has sought to render the present edition 
still more worthy than its predecessors. Every portion of the work has been thoroughly revised, 
several new chapters and a number of new illustrations have been introduced, and the most 
painstaking care has been bestowed to make it a full and trustworthy guide for the student and 
practitioner. To accommodate the numerous additions the size of the page has been enlarged, 
notwithstanding which the number of pages has been increased by nearly one hundred and fifty; 
in fact, the present edition contains nearly one -third more matter than the preceding, notwith- 
standing which it has been kept at the former very moderate price. The work, it is therefore 
hoped, will continue to maintain its position as the favorite book for consultation by all who 
have to treat this frequent and important class of diseases. 

led to more strongly than ever recommend it to the 
students and to the practitioners of our city as a work 
furnishing a very comprehensive treatise on the 



From Prof. Fordyce Barker, Bellevue Hospital 
Medical College, New York. 

A work which I estimate very highly and which I 
have always taken every opportunity to commend 
to students and the profession. I have carefully 
looked over this edition, and comparing it with the 
two former ones, I have been greatly impressed with 
the conscientious labor, as well as the ability, with 
which Professor Thomas has kept the work up to 
represent the advanced and progressing science of 
the day. 

From Prof. De Laskik Miller, Rush Medical 
College, Chicago. 
My appreciation of the work is indicated by the 
fact that I always mention it first when recommending 
works on this department to students or others. 

From Prof. J. Algernon Temple, Trinity College, 
Toronto. 
I can only say that in my opinion it is now the 
most complete work of its kind. The well-known 
reputation of the author and the many improvements 
in this edition place it in the foremost rank of medical 
literature. I shall have great pleasure in recom- 
mending it to my class. 

From Prof. Alex. J. C. Skene, Long Island College 

Hospital. 
This edition shows that the professor is determined 
to keep fully up to the times. I shall have the plea- 
sure of continuing to recommend this work to my 
cla.ss of students as the best on the subject to be 
found anywhere. 

From Prof. J. S. D. Cullen, Medical College of 
Virginia. 

A work which I prize very much both for the text 
and for the admirable manner in which it is pub- 
lished. It is the text-book which I recommend to 
my class and to my professional friends. 

From Prof. F. M. Eobertson, Charleston Medical 

College. 
I have no doubt that I shall find it worthy of even 
greater commendation than the preceding editions, 
as I find that it has been greatly enlarged and brought 
fully up with the times. 

From Prof. Frank Wells, Cleveland Medical 
College. 
The book has been for some time used in our 
school, and on the perusal of the new edition I am 



subject. 

From Prof. A.. F. A. King, National Medical College, 
Washington, D. C. 
On referring to it for advice in regard to some difli- 
cult cases now under treatment I have been delighted 
with its practical character, and shall take pleasure 
in recommending it as a text-book to my class. 

From Prof. J. C. Shrader, Ioioa State University. 
I shall take great pleasure in recommending it to 
the students in the Medical Department of the Iowa 
State University, as the standard work on gynaeco- 
logy- 

Its able author need not fear comparison between 
it and any similar work in the English language; 
nay more, as a text-book for students and as a guide 
for practitioners, we believe it is unequalled. In the 
libraries of reading physicians we meet with it oftener 
than any other treatise on diseases of women. We 
conclude our brief review by repeating the hearty 
commendation of this volume given when we com- 
menced : if either student or practitioner can get but 
one book on diseases of women, that book should be 
"Thomas." — Am. Journ. Med. Sciences, April, 1S72. 

Of the work itself, in the original block, we need 
hardly make any criticism at this date. It has firmly 
established itself as the American text-book of gynae- 
cology. Without being prolix, it treats of the disor- 
ders to which it is devoted, fully, perspicuously, and 
satisfactorily. It will be found a treasury of know- 
ledge to every physician who turns its pages. — Am. 
Journ. of Syphilography, April, 1872. 

No book in American medical literature has been 
so flatteringly received by the profession as this, and 
no one making the least pretensions to the study of 
uterine diseases can do without it. For clearness of 
style and therapeutics, it has no parallel. — Va. Clin. 
Record, April, 1S72. 

It better represents the present condition of gynje- 
cology than any work in the English language of which 
we know. Want of space forbids our entering into 
details ; nor is it necessary, for all our readers who 
are not already supplied with a copy of one of the 
previous editions will be sure to get this ; that is, if 
at all interested in the treatment of diseases of wo- 
men.— American Practitioner, April, 1872. 



HENRY C. LEA, Philadelphia. 



WORKS ON DISE ASES OF CHILDREN. 

SMITH ON WASTING DISEASES OF CHILDREN. 



m 



THE WASTING DISEASES OF INFANTS AND CHILDREN, 

By EUSTACE SMITH, M.D. 

Second American, from the Second and Enlarged London Edition. 

In one very, handsome octavo volume of 266 pages • extra cloth, $2 50. (Just Issued.) 



The final chapter on the diet and treatment of chil- 
dren in health and disease will be found especially 
useful to the junior practitioner, who is often at a loss 
in the management of children as regards the food to 
be administered It contains very minute and elabo- 
rate directions, and scales of dieting for different ages 
and conditions. We are glad to be able to recommend 
this work as one of sterling merit, and one which we 
have no doubt will be very favorably received and 
considered by the profession. — Dublin Quarterly 
Journal, Aug. 1871. 

As the first edition of this admirable work was re- 
viewed carefully in this journal, it is unnecessary to 
add much in regard to it. It has been enlarged by the 
addition of most valuable matter in connection with 
mucous diarrhoea, and the proper diet for invalid 



children. The author, as physician to the largest free 
Dispensary for children in London, has enjoyed an 
experience equalled by few, and surpassed by none. 
—Richmond and Louisville Medical Journal, Aug. 
1871. 

In a highly creditable manner the doctor has ex- 
plored this important field, and has brought out prac- 
tically the prominent salient points on the causes, 
diagnosis, prognosis, pathology, morbid anatomy, and 
the treatment of the^ diseases of childhood of which 
wasting is a symptom. The clinical facts thus made 
applicable give this work a special value. It is a 
book well worthy of careful perusal, and we would 
cordially recommend it to those who are interested 
in the diseases of infancy and childhood. — The New 
York Journ. of Psychological Medicine, April, 1S72. 



'WEST ON CHILDREN. 



LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 

By CHARLES WEST, 

Physician to the Hospital for Sick Children, &c. 

Fourth American, from the .Fifth and Revised English Edition. 

In one large and handsome octavo volume of 656 pages ; cloth, $4 50 ; leather, $5 50. 



The work of "West on the Diseases of Children is 
translated into the chief European languages, and 
extensively used ; and the reason is, we believe, sim- 
ply, that there is nothing to be found in any language 
at all equal to it.— Edinburgh Med. Journal, May, 
1869. 



All our readers are, doubtless, familiar with Dr. 
West's admirable volume, and will welcome the ap- 
pearance of a new edition. No praise is needed of a 
book so well known, which has placed its author in 
the first rank of British physicians, and gained him 
an enduriug reputation as an authority on infantile 
disease. — Brit, and For. Med.-Chir. Rev., Oct. 1870. [ 

By the same Author— Just Issued. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. 

Being the Lumleian Lectures delivered at the Royal College of Physicians of London, in 
March, 1871. In on« neat volume, small 12mo. ; cloth, $1. 

most difficult class of disease, we recommend it to 
their study. — St. Louis Medical and Surgical Jour- 
nal, Jan. 1S72. 



"With the assurance to our readers that this little 
book abounds in valuable practical hints which will 
assist them in the treatment of this, confessedly the 



CONDIE ON CHILDREN-. 



A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

By D. FRANCIS CONDIE, M.D. 

SIXTH IBIDITIOlXr, THOEOUGHLY REVISED. 
In one large and handsome octavo volume of nearly 800 closely printed pages ; extra cloth, $5 25 ; 

leather, $6 25. 

gone a careful and thorough revision, and the ad- 
vances recently made in our knowledge of the various 
diseases of childhood have been carefully incorpo- 
rated in the several chapters. This will be manifest 
on a comparison of the present with the previous 
edition. — Am. Journ. Med. Sciences, April, 186S. 



A work which has passed through five bona fide 
editions, and of which a sixth has been called for, 
may be regarded as being beyond the bounds of cri- 
ticism ; that high tribunal, the profession, having 
already recorded a verdict in its favor. All that is 
needed, in a notice of the present edition of Dr. Con- 
die's well-known treatise, is to state that it has under- 



GUERSANT ON SURGICAL DISEASES OF CHILDREN. 

SURGICAL DISEASES OfTnFANTS AND CHILDREN. 

By M. P. GUERSANT, 

Honorary Surgeon to the Hospital for Sick Children, Paris. 

Translated by RICHARD J. DUNGLISON, M.D. 

This work, now appearing in the "Medical News and Library," will be continued to comple- 
tion in 1872, when it will be issued separately in a handsome octavo volume of nearly 400 pages. 
It will be found to contain much which, while of everyday importance to the practitioner, can 
scarcely be found in the ordinary text-books. 



HENRY C. LEA, Philadelphia. 



THEORY C. LIEN'S 

(LATE LEA & BLANCHARD'S) 

OLAS SIIETIEIID CATALOG TTIEI 

OF 

MEDICAL AND SUEGIOAL PUBLICATIONS. 



In asking the attention of the profession to the works contained in the following 
pages, the publisher would state that no pains are spared to secure a continuance of 
the confidence earned for the publications of the house by their careful selection and 
accuracy and finish of execution. 

The printed prices are those at which books can generally be supplied by booksellers 
throughout the United States, who can readily procure for their customers any works 
not kept in stock. Where access to bookstores is not convenient, books will be sent 
by mail post-paid on receipt of the price, but no risks are assumed either on the 
money or the books, and no publications but my own are supplied. Gentlemen will 
therefore in most cases find it more convenient to deal with the nearest bookseller. 

An Illustrated Catalogue, of 64 octavo pages, handsomely printed, will be for- 
warded by mail, postpaid, on receipt of ten cents. 

HENRY C. LEA. 
Nos. 706 and 708 Sansom St., Philadelphia, March, 1872. 



ADDITIONAL INDUCEMENT FOR SUBSCRIBERS TO 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 



TE&EE MEDIGAL JOUEffALS, containing over 2000 LAKGE PAGES, 

Free of Postage, for SIX DOLLARS Per Annum, 



TEEMS FOB 1872: 



The American Journal of the Medical Sciences, and ] Five Dollars per annum, 
The Medical News and Library, both free of postage, j in advance. 

OK, 

The American Journal of the Medical Sciences, published quar-] y. -^ „ 

terly (1150 pages per annum), with j ' ° ara 

The Medical News and Library, monthly (384 pp. per annum), and } per annum 
The Half-Yearly Abstract of the Medical Sciences, published | . , 

Feb. and August (600 pages per annum), all free of postage. J • a vance - 

SEPARATE SUBSCRIPTIONS TO 

The American Journal of the Medical Sciences, subject to postage when not paid 

for in advance, Five Dollars. 
The Medical News and Library, free of postage, in advance, One Dollar. 
The Half-Yearly Abstract, Two Dollars and a Half per annum in advance. Single 

numbers One Dollar and a Half. 

It is manifest that only a very wide circulation can enable so vast an amount of 
valuable practical matter to be supplied at a price so unprecedented!} 7 low. The pub- 
lisher, therefore, has much gratification in stating that the rapid and steady increase 
in the subscription list promises to render the enterprise a permanent one, and it is 
with especial pleasure that he acknowledges the valuable assistance spontaneously 
rendered by so many of the old subscribers to the "Journal," who have kindlv made 
1 



2 Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 

known among their friends the advantages thus offered and have induced them to 
subscribe. Relying upon a continuance of these friendly exertions, he hopes to be 
able to maintain the unexampled rates at which these works are now supplied, and to 
succeed in his endeavor to place upon the table of every reading practitioner in the 
United States a monthly, a quarterly, and a half-yearly periodical at the comparatively 
trifling cost of Six Dollars per annum. 

These periodicals are universally known for their high professional standing in their 
several spheres. 

THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
Edited by ISAAC HAYS, M. D., 
is published Quarterly, on the first of January, April, July, and October. Each 
number contains nearly three hundred large octavo pages, appropriately illustrated, 
wherever necessary. It has now been issued regularly for nearly fifty years, during 
almost the whole of which time it has been under the control of the present editor. 
Throughout this long period, it has maintained its position in the highest rank of 
medical periodicals both at home and abroad, and has received the cordial support of 
the entire profession in this country. Among its Collaborators will be found a large 
number of the most distinguished names of the profession in every section of the 
United States, rendering the department devoted to 

ORIGINAL COMMUNICATIONS 
full of varied and important matter, of great interest to all practitioners. Thus, during 
1871, articles have, appeared in its pages from ninety-eight gentlemen of the highest 
standing in the profession throughout the United States* 

Following this is the "Keview Department," containing extended and impartial 
reviews of all important new works, together with numerous elaborate "Analytical 
and Bibliographical Notices" of nearly all the medical publications of the day. 

This is followed by the "Quarterly Summary of Improvements and Discoveries 
in the Medical Sciences," classified and arranged under different heads, presenting 
a very complete digest of all that is new and interesting to the physician, abroad as 
well as at home. 

Thus, during the year 1871, the "Journal" furnished to its subscribers One 
Hundred and Twenty-two Original Communications, Sixty- four Reviews and Biblio- 
graphical Notices, and Three Hundred and five articles in the Quarterly Summaries, 
making a total of about Five Hundred articles emanating from the best professional 
minds in America and Europe. 

That the efforts thus made to maintain the high reputation of the " Journal" are 
successful, is shown by the position accorded to it in both America and Europe as a 
national exponent of medical progress : — 

Dr. Hays keeps his great American Quarterly, in \ matter it contains, and has established for itself a 
which he is now assisted by Dr. Minis Hays, at the j reputation in every country where medicine is cul- 
head of his country^ medical periodicals.— Dublin j tivated as a science.— Brit, and For. Med.-Chirurg. 

Review, April, 1S71.. 



One of the best of its kind. — London Lancet, Ang. 
20, 1S70. 

Almost the only one that circulates everywhere, 
all over the Union and in Europe. — London Medical 
Times; Sept. 5, 1S68. 



Medical Press and Circular, March S, 1871 

Of English periodicals the Lancet, and of American 
the Am. Journal of the Medical Sciences, are to be 
regarded as necessities to the reading practitioner.— 
N. Y. Medical Gazette, Jan. 7, 1871. 

The American Journal of the Medical Sciences 
yields to none in the amount of original and borrowed 

The subscription price of the "American Journal of the Medical Sciences " has 
never been raised, during its long career. It is still Five Dollars per annum ; and 
when paid for in advance, the subscriber receives in addition the "Medical News and 
Library," making in all about 1500 large octavo pages per annum, free of postage. 

II. 

THE MEDICAL NEWS AND LIBRARY 

is a monthly periodical of Thirty-two large octavo pages, making 384 pages per 
annum. Its "News Department" presents the current information of the day, with 
Clinical Lectures and Hospital Gleanings; while the " Library Department" is de- 
voted to publishing standard works on the various branches of medical science, paged 
separately, so that they can be removed and bound on completion. In this manner 
subscribers have received, without expense, such works as " Watson's Practice," 
"Todd and Bowman's Physiology," "West on Children," "Malgaigne's Surgery," 
&c. &c. And in 1872 will be continued to completion the valuable practical treatise 



* Communications are invited from gentlemen in all parts of the country. Elaborate articles inserted 
by the Editor are paid for by the Publisher. 



Henry C. Lea's Publications — (Am. Journ. Med. Sciences). 3 
of M. P. Guersant on the Surgical Diseases op Children, translated by R. J. 

DuNGLISON, M. D. 

As stated above, the subscription price of the "Medical News and Library" is 
One Dollar per annum in advance ; and it is furnished without charge to all advance 
paying subscribers to the "American Journal op the Medical Sciences." 

III. 

THE HALF-YEARLY ABSTRACT OF THE MEDICAL SCIENCES 

is issued in half-yearly volumes, which will be delivered to subscribers about the first 
of February, and first of August. Each volume contains about 300 closely printed 
octavo pages, making about six hundred pages per annum. 

" Banking's Abstract" has now been published in England regularly for more than 
twenty years, and has acquired the highest reputation for the ability and industry 
with which the essence of medical literature is condensed into its pages. It pur- 
ports to be "A Digest of British and Continental Medicine, and of the Progress of 
Medicine and the Collateral Sciences" and it is even more than this, for America is 
largely represented in its pages. It draws its material not only from all the leading 
American, British, and Continental journals, but also from the medical works and 
treatises issued during the preceding six months, thus giving a complete digest of 
medical progress. Each article is carefully condensed, so as to present its substance 
in the smallest possible compass, thus affording space for the very large amount of infor- 
mation laid before its readers. The volumes of 1871, for instance, have contained 

FORTY-FIVE ARTICLES ON GENERAL QUESTIONS IN MEDICINE. 

ONE HUNDRED AND THIRTY ARTICLES ON SPECIAL QUESTIONS IN MEDICINE. 

ELEVEN ARTICLES ON FORENSIC MEDICINE 

ONE HUNDRED AND THREE ARTICLES ON THERAPEUTICS. 

FORTY-THREE ARTICLES ON GENERAL QUESTIONS IN SURGERY. 

ONE HUNDRED AND TWENTY-ONE ARTICBES ON SPECIAL QUESTIONS IN SURGERY 

EIGHTY-EIGHT ARTICLES ON MIDWIFERY AND DISEASES OF WOMEN AND CHILDREN 

FIVE ARTICLES IN APPENDIX. 

Making in all over five hundred and fifty articles in a single year. Each volume, 
moreover, is systematically arranged, with an elaborate Table of Contents and a very 
full Index, thus facilitating the researches of the reader in pursuit of particular sub- 
jects, and enabling him to refer without loss of time to the vast amount of information 
contained in its pages. 

The subscription price of the "Abstract," mailed free of postage, is Two 
Dollars and a Half per annum, payable in advance. Single volumes, .$1 50 each. 

As stated above, however, it will be supplied in conjunction with the "American 
Journal of the Medical Sciences" and the "Medical News and Library," the 
whole free of postage, for Six Dollars per annum in advance. 

For this small sum the subscriber will therefore receive three periodicals costing 
separately Eight Dollars and a Half, each of them enjoying the highest reputation in 
its class, containing in all over two thousand pages of the choicest reading, and pre- 
senting a complete view of medical progress throughout both hemispheres. 

In this effort to bring so large an amount of practical information within the reach 
of every member of the profession, the publisher confidently anticipates the friendly 
aid of all who are interested in the dissemination of sound medical literature. He 
trusts, especially, that the subscribers to the "American Medical Journal" will call 
the attention of their acquaintances to the advantages thus offered, and that he will 
be sustained in the endeavor to permanently establish medical periodical literature on 
a footing of cheapness never heretofore attempted. 

PREMIUM FOR NEW SUBSCRIBERS. 

Any gentleman who will remit the amount for two subscriptions for 1872, one of 
which must be for a new subscriber, will receive as a premium, free by mail, a copy of 
the new edition of Tanner's Clinical Manual, for advertisement of which see p. 5, 
or of Chambers' Restorative Medicine (see p. 17), or West on Nervous Disorders 
of Children (see p. 21). 

%* Gentlemen desiring to avail themselves of the advantages thus offered will do 
well to forward their subscriptions at an early day, in order to insure the receipt of 
complete sets for the year 1871, as the constant increase in the subscription list almost 
always exhausts the quantity printed shortly after publication. 

IgiT The safest mode of remittance is by bank check or postal money order, drawn 
to tne order oi the undersigned. Where these are not accessible, remittances for the 
"Journal" may be made at the risk of the publisher, by forwarding in registered 
letters. Address, 

HENRY C. LEA, 
Nob. 706 and 708 Sansom St.. Philadelphia, Fa. 



Henry C. Lea's Publications— (Dictionaries). 



jyUNGLISON {ROBLET), 31. D., 

Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

MEDICAL LEXICON; A Dictionary of Medical Science: Con- 
taining a concise explanation of the various Subjects and Terms of Anatomy, Physiology, 
Pathology, Hygiene. Therapeutics, Pharmacology, Pharmacy, Surgery, Obstetrics, Medical 
Jurisprudence, and Dentistry. Notices of Climate and of Mineral Waters; Formulae foT 
Officinal, Empirical, and Dietetic Preparations; with the Accentuation and Etymology oi 
the Terms, and the French and other Synonymes ; so as to constitute a French as well as 
English Medical Lexicon. Thoroughly Revised, and very greatly Modified and Augmented. 
In one very large and handsome royal octavo volume of 1048 double-columned pages, in 
small type; strongly done up in extra cloth, $6 00 ; leather, raised bands, $6 75. 
The object of the author from the outset has not been to make the work a mere lexicon or 
dictionary of terms, but to afford, under each, a condensed view of its various medical relation?, 
and thus to render the work an epitome of the existing condition of medical science. Starting 
with this view, the immense demand which has existed for the work has enabled him, in repeated 
revisions, to augment its completeness and usefulness, until at length it has attained the position 
of a recognized and standard authority wherever the language is spoken. The mechanical exo- 
cution of this edition will be found greatly superior to that of previous impressions. By enlarging 
the size of the volume to a royal octavo, and by the employment of a small but clear type, on 
extra fine paper, the additions have been incorporated without materially increasing the bulk of 
the volume, and the matter of two or three ordinary octavos has been compressed into the space 
of one not unhandy for consultation and reference. 

It is undoubtedly the most complete and useful 
medical dictionary hitherto published in this country. 
— Chicago Med. Examiner, February, 1S65. 

What we take to be decidedly the best medical dic- 



It would be a work of supererogation to bestow a 
word of praise upon this Lexicon. "We can only 
wonder at the labor expended, for whenever we refer 
to its pages for information we are seldom disap- 
pointed in finding all we desire, whether it be in ac- 
centuation, etymology, or definition of terms. — New 
York Medical Journal, November, 1865. 

It would be mere waste of words in us to express 
our admiration of a work which is so universally 
and deservedly appreciated. The most admirable 
work of its kind in the English language. As a book 
of reference it is invaluable to the medical practi- 
tioner, and in every instance that we have turned 
over its pages for information we have been charmed 
by the clearness of language and the accuracy of 
detail with which each abounds. We can most cor- 
diallv and confidently commeud it to our readers. — 
Glasgow Medical Journal, January, 1866. 

A work to which there is no equal in the English 
language. — Edinburgh Medical Journal. 

It is something more than a dictionary, and some- 
thing less than an encyclopedia. This edition of the 
well-known work is a great improvement on its pre- 
decessors. The book is one of the very few of which 
it may be said with truth that every medical man 
should possess it. — London Medical Times, Aug. 26, 
1865. 

Few works of the class exhibit a grander monument 
of patient research and of scientific lore. The extent 
of the sale of this lexicon is sufficient to testify to its 
usefulness, and to the great service conferred by Dr. 
Robley Dunglison on' the profession, and indeed on 
others, by its issue. — London Lancet, May 13, 1S65. 

The old edition, which is now superseded by the 
new, has been universally looked upon by the medi- 
cal profession as a work of immense research and 
vreat value. The new has increased usefulness ; for 
medicine, in all its branches, has been making such 
progress that many new terms and subjects have re- 
cently been introduced : all of which may be found 
fully defined in the present edition. We know of no 
other dictionary in the English language that can 
bear a comparison with it in point of completeness of 
subjects and accuracy of statement.— N. Y. Drug- 
gists' Circular, 1865. 

For many years Dunglison' s Dictionary has been 
the standard book of reference with most practition- 
ers in this country, and we can certainly commend 
this work to the renewed confidence and regard of 
our readers. — Cincinnati Lancet, April, 1865. 



tionary in the English language. The present edition 
is brought fully up to the advanced state of science. 
For many a long year "Dunglison" has been at our 
elbow, a constant companion and friend, and we 
greet him in his replenished and improved form with 
especial satisfaction. — Pacific Med. and Surg. Jour* 
nal, June 27, 1865. 

This is, perhaps, the book of all others which the 
physician or surgeon should have on his shelves. It 
is more needed at the present day than a few years 
back. — Canada Med. Journal, July, 1865. 

It deservedly stands at the head, and cannot be 
surpassed in excellence. — Buffalo Med. and Surg. 
Journal, April, 1S65. 

We can sincerely commend Dr. Dunglison's work 
as most thorough, scientific, and accurate. We have 
tested it by searching its pages for new terms, which 
have abounded so much of late in medical nomen- 
clature, and our search has been successful in every 
instance. We have been particularly struck with the 
fulness of the synonymy and the accuracy of the de- 
rivation of words. It is as necessary a work to every 
enlightened physician as Worcester's English Dic- 
tionary is to every one who would keep up his know- 
ledge of the English tongue to the standard of the 
present day. It is, to our mind, the most complete 
work of the kind with which we are acquainted.— 
Boston Med. and Surg. Journal, June 22, 1865. 

We are free to confess that we know of no medical 
dictionary more complete ; no one better, if so well 
adapted for the use of the student; no one that may 
be consulted with more satisfaction by the medical 
practitioner. — Am. Jour. Med. Sciences, April, 1865. 

The value of the present edition has been greatly 
enhanced by the introduction of new subjects and 
terms, and a more complete etymology and accentua- 
tion, which renders the work not only satisfactory 
and desirable, but indispensable to the physician. — 
Chicago Med. Journal, April, 1S65. 

No intelligent member of the profession can or will 
be without it. — St. Louis Med. and Surg. Journal, 
April, 1865. 

It has the rare merit that it certainly has no rival 
in the English language for accuracy and extent o! 
references. — London Medical Gazette. 



B 



OBLYN [RICHARD D.), M.D. 



A DICTIONARY OF THE TERMS USED IN MEDICINE AND 

THE COLLATERAL SCIENCES. Revised, with numerous additions, by Isaac Havs, 
M.D., Editor of the "American Journal of the Medical Sciences." In one large royal 
12mo.' volume of over 500 double-columned pages ; extra cloth, $1 50 ; leather, $2 00. 
It is the best book of definitions we have, and ought always to be upon the student's table.— Southern 
Med. and Surg. Journal. 



Henry C. Lea's Publications — (Manuals). 



"fiTEILL (JOHN), M.D., and CjMITH {FRANCIS G.), M.D., 

Prof, of the Institutes of Medicine in the Univ. of Penrm. 

AN ANALYTICAL COMPENDIUM OF THE VARIOUS 

BRANCHES OP MEDICAL SCIENCE; for the Use and Examination of Students. A 
new edition, revised and improved. In one very large and handsomely printed royal 12m<<. 
volume, of about one thousand pages, with 374 wood cuts, extra cloth, $4; strongly hound 
in leather, with raised hands, $4 75. 



The Compend of Drs. Neill and Smith is incompara- 
bly the most valuable work of its class ever published 
in this country. Attempts have been made in various 
quarters to squeeze Anatomy, Physiology, Surgery, 
the Practice of Medicine, Obstetrics, Materia Medica, 
and Chemistry into a single manual; but the opera- 
tion has signally failed in the hands of all up to the 
advent of " Neill and Smith's' ' volume, which is quite 
a miracle of success. The outlines of the whole are 
admirably drawn and illustrated, and the authors 
are eminently entitled to the grateful consideration 
of the student of every class. — N. 0. Med. and Surg. 
Journal. 

There are but few s+udents or practitioners of me- 
dicine unacquainted with the former editions of this 
anassuming though highly instructive work. The 
whole science of medicine appears to have been sifted, 
as the gold-bearing sands of El Dorado, and the pre- 



cious facts treasured up in this little volume. A com- 
plete portable library so condensed that the student 
may make it his constant pocket companion. — West- 
ern Lancet. 

In the rapid course of lectures, where work for tre 
students is heavy, and review necessary for an exa- 
mination, a compend is not only valuable, but it is 
almost a sine qua non. The one before us is, in mof?t 
of the divisions, the most unexceptionable of all books 
of the kind that we know of. Of course it is useless 
for us to recommend it to all last course students, but 
there is a class to whom we very sincerely commend 
this cheap book as worth its weight in silver — that 
class is the graduates in medicine of more than ten 
years' standing, who have not studied medicine 
since. They will perhaps find out from it that the 
science is not exactly now what it was when they 
left it off.— The Stethoscope. 



JJARTSHORNE {HENRY), M. D., 

Professor of Hygiene in the University of Pennsylvania. 

A CONSPECTUS OF THE MEDICAL SCIENCES; containing 

Handbooks on Anatomy, Physiology, Chemistry, Materia Medica, Practical Medicine, 
Surgery, and Obstetrics. In one large royal 12mo. volume of 1000 closely printed pages*, 
with over 300 illustrations on wood, extra cloth, $4 50 ; leather, raised bands, $5 2ft. 
{Jit st Issued.) 
The ability of the author, and his practical skill in condensation, give assurance that this 
work will prove valuable not only to the student preparing for examination, but also to the prac- 
titioner desirous of obtaining within a moderate compass, a view of the existing condition of the 
various departments of science connected with medicine. 

less valuable to the beginner. Every medical student 
who desires a reliable refresher to his memory whea 
the pressure of lectures and other college work crowds 
to prevent him from having an opportunity to drink 
deeper in the larger works, will find this one of tho 
greatest utility. It is thoroughly trustworthy from 
beginning to end; and as we have before intimated, 
a remarkably truthful outline sketch of the present 
state of medical science. We could hardly expect it 
should be otherwise, however, under the charge of 
such a thorough medical scholar as the author has 



This work is a remarkably complete one in its way, 
and comes nearer to our idea of what a Conspectus 
should be than any we have yet seen. Prof. Harts- 
horne, with a commendable forethought, intrusted 
the preparation of many of the chapters on special 
subjects to experts, reserving only anatomy, physio- 
logy, and practice of medicine to himself. As a result 
we have every department worked up to the latest 
date and in a refreshingly concise and lucid manner. 
There are an immense amount of illustrations scat- 
tered throughout the work, and although they have 
often been seen before in the various works upon gen- 
eral and special subjects, yet they will be none the 



already proved himself to be. — N. York Med. Record, 
March 15, 1S69. 



J UDLOW {J.L.), M.D. 

A MANUAL OF EXAMINATIONS upon Anatomy, Physiology, 

Surgery, Practice of Medicine, Obstetrics, Materia Medica, Chemistry, Pharmacy, and 
Therapeutics. To which is added a Medical Formulary. Third edition, thoroughly revised 
and greatly extended and enlarged. With 370 illustrations. In one handsome royal 
12mo. volume of 816 large pages, extra cloth, $3 25'; leather, $3 75. 
The arrangement of this volume in the form of question and answer renders it especially suit- 
able for the office examination of students, and for those preparing for graduation. 

/TANNER {THOMAS HAWKES), M.D., #c. 

X A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAG- 

NOSIS. Third American from the Second London Edition. Revised and Enlarged by 

Tilbury Fox, M. D., Physician to the Skin Department in University College Hospital. 

&c. In one neat volume small 12mo., of about 375 pages, extra cloth. $150. (Just Issued.) 

*%.* By reference to the " Prospectus of Journal" on page 3, it will be seen that this work ig 

offered as a premium for procuring new subscribers to the "American Journal of the Medical 

Sciences." 

Taken as a whole, it is the most compact vade me- I The objections commonly, and justly, urged against 
cum for the use of the advanced student and junior ] the general run of "compends," "conspectuses," and 



practitioner with which we are acquainted. — Boston 
Med. and Surg. Journal, Sept. 22, 1S70. 

It contains so much that is valuable, presented in 
so attractive a form, that it can hardly be spared 
even in the presence of more full and complete works. 
The additions made to the volume by Mr. Fox very 
materially enhance its value, and almost make it a 
new work. Its convenient size makes it a valuable 
companion to the country practitioner, and if con- 
stantly carried by him, would often render him good 
service, and relieve many a doubt and perplexity. — 
Leavenworth Med. Herald, July, 1870. 



other aids to indolence, are not applicable to this little 
volume, which contains in concise phrase just those 
practical details that are of most use in daily diag- 
nosis, but which the young practitioner finds it diffi- 
cult to carry always in his memory without some 
quickly accessible means of reference. Altogether, 
the book is one which we can heartily commend 10 
those who have not opportunity for extensive read- 
ing, or who, having read much, still wish an occa- 
sional practical reminder. — K Y. Med. Gazette, Nov. 
10, 1S70. 



6 Henry C. Lea's Publications — (Anatomy). 

QRAY [HENRY), F.R.S., 

Lecturer on Anatomy at St. George's Hospital, London. 

ANATOMY, DESCRIPTIVE AND SURGICAL. The Drawings by 

H. V. Carter, M. D., late Demonstrator on Anatomy at St. George's Hospital ; the Dissec- 
tions jointly by the Author and Dr. Carter. A new American, from the fifth enlarged 
and improved London edition. In one magnificent imperial octavo volume, of nearly 900 
pages, with 465 large and elaborate engravings on wood. Price in extra cloth, $6 00 ; 
leather, raised bands, $7 00. (Jtist Issued.) 
The author has endeavored in this work to cover a more extended range of subjects than is cus- 
tomary in the ordinary text-books, by giving not only the details necessary for the student, but 
also the application of those details in the practice of medicine and surgery, thus rendering it both 
a guide for the learner, and an admirable work of reference for the active practitioner. The en- 
gravings form a special feature in the work, many of them, being the size of nature, nearly all 
original, and having the names of the various parts printed on the body of the cut, in place of 
figures of reference, with descriptions at the foot. They thus form a complete and splendid series, 
which will greatly assist the student in obtaining a clear idea of Anatomy, and will also serve to 
refresh the memory of those who may find in the exigencies of practice the necessity of recalling 
the details of the dissecting room; while combining, as it does, a complete Atlas of Anatomy, with 
a thorough treatise on systematic, descriptive, and applied Anatomy, the work will be found of 
essentialuse to all physicians who receive students in their offices, relieving both preceptor and 
pupil of much labor in laying the groundwork of a thorough medical education. 

Notwithstanding the enlargement of this edition, it has been kept at its former very moderate 
price, rendering it one of the cheapest works now before the profession. 



The illustrations are beautifully executed, and ren- 
der this work an indispensable adjunct to the library 
of the surgeon. Tbis remark applies with great force 
to those surgeons practising at a distance from our 
la7-ge cities, as the opportunity of refreshing their 
memory by actual dissection is not always attain- 
able.— Canada Med. Journal, Aug. 1S70. 

The work is too well known and appreciated by the 
profession to need any comment. No medical man 
can afford to be without it, if its only merit were to 
serve as a reminder of that which so soon becomes 
forgotten, when not called into frequent use, viz., the 
relations and names of the complex organism of the 
human body. The present edition is much improved. 
—California Med. Gazette, July, 1S70. 

Gray's Anatomy bas been so long the standard of 
perfection with every student of anatomy, that we 
need do no more than call attention to the improve- 
ment in the present edition. — Detroit Review of Med. 
and Pharm., Aug. 1870. 



From time to time, as successive editions have ap- 
peared, we have had much pleasure in expressing 
the general judgment of the wonderful excellence of 
Gray's Anatomy. — Cincinnati Lancet, July, 1870. 

Altogether, it is unquestionably the most complete 
and serviceable text-book in anatomy that has ever 
been presented to the student, and forms a striking 
contrast to the dry and perplexing volumes on the 
same subject through which their predecessors strug- 
gled in days gone by. — N. T. Med. Record, June 15, 
1870. 

To commend Gray's Anatomy to the medical pro- 
fession is almost as much a work of supererogation 
as it would be to give a favorable notice of the Bibl8 
in the religious press. To say that it is the most 
complete and conveniently arrauged text book ofits 
kind, is to repeat what each generation of students 
has learned as a tradition of the elders, and verified 
by personal experience. — N. Y. Med. Gazette, Dec. 
17, 1870. 



&31ITH [HENRY E.), M.D., and TJORNER [ WILLIAM E.), M.D., 

Prof, of Surgery in the Univ. of Penna., Sec. Late Prof, of Anatomy in the Univ. ofPenna., &e. 

AN ANATOMICAL ATLAS, illustrative of the Structure of the 

Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred 

and fifty beautiful figures. $4 50. 
Tbe plan of this Atlas, which renders it so pecu- I the kind that has yet appeared; and we must add, 
liarly convenient for the student, and its superb ar- | the very beautiful manner in which it is "-got up," 
ti^tical execution, have been already pointed out. We is so creditable to the country as to be flattering to 
must congratulate the student upon the completion our national pride. — American Medical Journal. 
of this Atlas, as it is the most convenient work of I 



OHARPEY ( WILLIAM), M.D., and Q VAIN [JONES £ RICHARD). 
HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph 

Leidy, M.D., Professor of Anatomy in the University of Pennsylvania. Complete in two 
large octavo volumes, of about 1300 pages, with 511 illustrations; extra cloth, $6 00. 
The very low price of this standard work, and its completeness in all departments of the subject, 
should command for it a place in the library of all anatomical students. 



LTODGES, [RICHARD M.), M.D., 

-*■-*- Late Demonstrator of Anatomy in the Medical Department of Harvard University. 

PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In 

one neat royal 12mo. volume, half-bound, $2 00. 
The object of this work is to present to the anatomical student a clear and concise description 
of that which he is expected to observe in an ordinary course of dissections. The author has 
endeavored to omit unnecessary details, and to present the subject in the form which many years' 
experience has shown him to be the most convenient and intelligible to the student. In the 
revision of the present edition, he has sedulously labored to render the volume more worthy of 
the favor with which it has heretofore been received. 



Henry C. Lea's Publications — (Anatomy) 



1 



fflILSON [ERASMUS), F.R.S. 

A SYSTEM OF HUMAN ANATOMY, General and Special. Edited 

by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical Col- 
lege of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In 
one large and handsome octavo volume, of over 600 large pages; extra cloth, $4 00; lea- 
ther, $5 00. 
The publisher trusts that the well-earned reputation of this long-established favorite will be 
more than maintained by the present edition. Besides a very thorough revision by the author, it 
has been most carefully examined by the editor, and the efforts of both have been directed to in- 
troducing everything which increased experience in its use has suggested as desirable to render it 
a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- 
tomy. The amount of additions which it has thus received may be estimated from the fact that 
tho present edition contains over one-fourth more matter than the last, rendering a smaller type 
and an enlarged page requisite to keep the volume within a convenient size. The author has not 
only thus added largely to the work, but he has also made alterations throughout, wherever there 
appeared the opportunity of improving the arrangement or style, so as to present every fact in its 
most appropriate manner, and to render the whole as clear and intelligible as possible. The editor 
has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased 
the number of illustrations, of which there are about one hundred and fifty more in this edition 
than in the last, thus bringing distinctly before the eye of the student everything of interest or 
importance. 

LIE ATE {CHRISTOPHER), F.R. C. S., 

•*■-*- Teacher of Operative Surgery in University College, London. 

PRACTICAL ANATOMY: A Manual of Dissections. From the 

Second revised and improved London edition. Edited, with additions, by W. W. Keen, 
M. D., Lecturer on Pathological Anatomy in the Jefferson Medical College, Philadelphia. 
In one handsome royal 12uio. volume of 578 pages, with 247 illustrations. Extra cloth, 
$3 50 ; leather, $4 00. (Just Issued.) 



Dr. Keen, the American editor of this work, in his 
preface, says: "In presenting this American edition 
of 'Heath's Practical Anatomy,' I feel that I have 
been instrumental in supplying a want long felt for 
a real dissector's manual," and this assertion of its 
editor we deem is fully justified, after an examina- 
tion of its contents, for it is really an excellent work. 
Indeed, we do not hesitate to say, the best of its class 
with which we are acquainted ; resembling Wilson 
in terse and clear description, excelling most of the 
so-called practical anatomical dissectors in the scope 
of the subject and practical selected matter. . . . 
In reading this work, one is forcibly impressed with 
the great pains the author takes to impress the sub- 
ject upon the mind of the student. He is full of rare 
and pleasing little devices to aid memory in main- 
taining its hold upon the slippery slopes of anatomy. 
— St. Louis Med. and Surg. Journal, Mar. 10, 1871. 

It appears to us certain that, as a guide in dissec- 
tion, and as a work containing facts of anatomy in 
brief and easily understood form, this manual is 
complete. This work contains, also, very perfect 
illustrations of parts which can thus be more easily 
uuderstood and studied; in this respect it compares 
favorably with works of much greater pretension. 



Such manuals of anatomy are always favorite works 
with medical students. We would earnestly recom- 
mend this one to their attention; it has excellences 
which make it valuable as a guide in dissecting, as 
well as in studying anatomy. — Buffalo Medical and 
Surgical Journal, Jan. 1S71. 

The first English edition was issued about six years 
ago, and was favorably received not only on account 
of the great reputation of its author, but also from 
its great value and excellence as a guide-book to the 
practical anatomist. The American edition has un- 
dergone some alterations and additions which will 
no doubt enhance its value materially. The conve- 
nience of the student has been carefully consulted in 
the arrangement of the text, and the directions given 
for the prosecution of certain dissections will be duly 
appreciated. — Canada Lancet, Feb. 1871. 

This is an excellent Dissector's Manual ; one which 
is not merely a descriptive manual of anatomy, but 
a guide to the student at the dissecting table, enabling 
him, though a beginner, to prosecute his work intel- 
ligently, and without assistance. The American edi- 
tor has made many valuable alterations and addi- 
tions to the original work. — Am. Journ. of Obstetrics, 
Feb. 1871. 



MACLISE {JOSEPH). 

SURGICAL ANATOMY. By Joseph Maclise, Surgeon. In one 

volume, very large imperial quarto; with 68 large and splendid plates, drawn in the be;-t 
style and beautifully colored, containing 190 figures, many of them the size of life; together 
with copious explanatory letter-press. Strongly and handsomely bound in extra cloth. 
Price $14 00. 
As no complete work of the kind has heretofore been published in the English language, the 
present volume will supply a want long felt in this country of an accurate and comprehensive 
Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- 
tain the exact relative positions of the various portions of the human frame towards each other 
and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty 
and finish of the very numerous illustrations, it will be observed that the price is so low as to 
place it within the reach of all members of the profession. 

We know of no work on surgical anatomy which refreshed by those clear and distinct dissections, 
can compete with it. — Lancet. 

The work of Maclise on surgical anatomy is of the 
highest value. In some respects it is the best publi- 
cation of its kind we have seen, and is worthy of a 
place in the libiary of any medical man, while the 
student could scarcely make a better investment than | 
this. — The Western Journal of Medicine and Surgery, j 

No such lithographic illustrations of surgical re- 
gions have hitherto, we think, been given. While 
the operator is shown every vessel and nerve where 
an operation is contemplated, the exact anatomist is i 



hich every one must appreciate who has a particle 
of enthusiasm. The English medical press has quite 
exhausted the words of praise, in recommending this 
admirable treatise. Those who have any curiosity 
to gratify, in reference to the perfectibility of the 
lithographic art in delineating the complex mechan- 
ism of the human body, are invited to examine our 
specimen copy. If anything will induce surgeons 
and students to patronize a book of such rare value 
and everyday importance to them, it will be a survey 
of the artistical skill exhibited in these fac-similee ol 
nature. — Boston Med. and Surg. Journal. 



HORNER'S SPECIAL ANATOMY AND HISTOLOGY. 
Eighth edition, extensively revised and modified. 



In 2 vols. 8vo., of over 1000 pages, with more than 
300 wood-cuts ; extra cloth, $ti 00. 



Henry C. Lea's Publications — (Physiology). 



11TARSHALL {JOHN), F. R. S., 

JJJL Professor of Surgery in University College, London, &c. 

OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. 

With Additions by Francis Gurney Smith, M. D., Professor of the Institutes of Medi- 
cine in the University of Pennsylvania, &c. With numerous illustrations. In one large 
and handsome octavo volume, of 1026 pages, extra cloth, $6 50 ; leather, raised bands. 

$7 50. 



In fact, in every respect, Mr. Marshall has present- 
ed us with a most complete, reliable, and .scientific 
work, and we feel that it is worthy our warmest 
commendation.— St. Louis Med. Reporter, Jan. 1869. 

This is an elaborate and carefully prepared digest 
of human and comparative physiology, designed for 
the use of general readers, but more especially ser- 
viceable to the student of medicine. Its style is con- 
cise, clear, and scholarly ; its order perspicuous and 
exaet, and its range of topics extended. The author 
and his American editor have been careful to bring 
to the illustration of the subject the important disco- 
veries of modern science in the various cognate de- 
partments of investigation. This is especially visible 
in the variety of interesting information derived from 
the departments of chemistry and physics. The great 
amount and variety of matter contained in the work 
is strikingly illustrated by turning over the copious 
index, covering twenty-four closely printed pages in 
double columns. — Silhman's Journal, Jan. 1869. 

We doubt if there is in the English language any 
compend of physiology more useful to the student 
than this work.— St. Louis Med. and Surg. Journal, 
Jan. 1869. 

It quite fulfils, in our opinion, the author's design 
of making it truly educational in its character — which 
is, perhaps, the highest commendation that can be 
asked. — Am. Journ. Med. Sciences, Jan. 1569. 

We may now congratulate him on having com- 
pleted the latest as well as the best summary of mod- 



ern physiological science, both human and compara- 
tive, with which we are acquainted. To speak of 
this work in the terms ordinarily used on such occa- 
sions would not be agreeable to ourselves, and would 
fail to do justice to its author. To write such a book 
requires a varied and wide range of knowledge, con- 
siderable power of analysis, correct judgment, skill 
in arrangement, and conscientious spirit. It must 
have entailed great labor, but now that the task has 
been fulfilled, the book will prove not only in valuable 
to the student of medicine ( and surgery, but service- 
able to all candidates in natural science examinations, 
to teachers in schools, and to the lover of nature gene- 
rally. In conclusion, we can only express the con- 
viction that the merits of the work will command for 
it that success which the ability and vast labor dis- 
played in its production so well deserve. — London 
Lancet, Feb. 22, 1S6S. 

If the possession of knowledge, and peculiar apti- 
tude and skill in expounding it, qualify a man to 
write an educational work, Mr. Marshall's treatise 
might be reviewed favorably without even opening 
the covers. There are few, if any, more accomplished 
anatomists and physiologists than the distinguished 
professor of surgery at University College ; and he 
has long enjoyed the highest reputation as a teacher 
of physiology, possessing remarkable powers of clear 
exposition and graphic illustration. We have rarely 
the pleasure of being able to recommend a text-book 
so unreservedly as this. — British Med. Journal, Jan. 
25, 1868. 



flARPENTER {WILLIAM B.), M.I)., F.R.S., 

^y Examiner in Physiology and Comparative Anatomy in the University of London. 

PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- 

cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new 
American from the last and revised London edition. With nearly three hundred illustrations. 
Edited, with additions, by Frajscis Gurney Smith, M. D., Professor of the Institutes of 
Medicine in the University of Pennsylvania, &c. In one very large and beautiful octavo 
volume, of about 900 large pages, handsomely printed; extra cloth, $5 50 ; leather, raised- 
bands, $6 50. 

We doubt not it is destined to retain a strong hold 
on public favor, and remain the favorite text-book in 
our colleges. — Virginia Medical Journal. 



With Dr. Smith, we confidently believe "that the 
present will more than sustain the enviable reputa- 
tion already attained by former editions, of being 
one of the fullest and most complete treatises on the 
subject in the English language." We know of none 
from the pages of which a satisfactory knowledge of 
the physiology of the human organism can be as well 
obtained, none better adapted for the use of such as 
take up the study of physiology in its reference tof 
the institutes and practice of medicine. — Am. Jour. 
Med. Sciences. 



The above is the title of what is emphatically the, 
great work on physiology ; and we are conscious that 
it would be a useless elfort to attempt to add any- 
thing to the reputation of this invaluable work, and 
can only say to all with whom our opinion has any 
influence, that it is our authority. — Atlanta Med. 
Journal. 



IDT THE SAME AUTHOR. 

PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Ameri- 

can, from the Fourth and Revised London Edition. In one large and handsome octavo 
volume, with over three hundred beautiful illustrations. Pp. 752. Extra cloth, $5 00. 
As a complete and condensed treatise on its extended and important subject, this work becomes 

a necessity to students of natural science, while the very low price at which it is offered places it 

within the reach of all. 



ZTIRKES {WILLIAM SENHOUSE), M.D. 

A MANUAL OE PHYSIOLOGY. A new American from the third 

and improved London edition. With two hundred illustrations. In one large and hand- 
some royal 12mo. volume. Pp. 586. Extra cloth, $2 25 ; leather, $2. 75. 



It is at once convenient iu size, comprehensive in 
design, and concise in statement, and altogether well 
adapted for the purpose designed. — St. Louis Med. 
and Surg. Journal. 

Tke phyei)Iogical reader will find it a most excel- 



lent guide in the study of physiology in its most ad- 
vanced and perfect form. The author has shown 
himself capable of giving details sufficiently ample 
in a condensed and concentrated shape, on a science 
in which it is necessary at once to be correct and not 
lengthened — Edinburgh Med. and Surg. Journal. 



Henry C. Lea's Publications — {Physiology). 



T)ALTOX {J. C), 31. D., 

-*S Professor of Physiology in the College of Physicians and Surgeons. New Tori-, &c. 

A TREATISE OX HOIAX PHYSIOLOGY. Designed for the use 

of Students and Prax-titioners of Medicine. Fifth edition, revised, with nearly three hun- 
dred illustrations on wood. In one very beautiful octavo volume, of over 700 pages, extia 
cloth, $5 25 ; leather, $6 25. {Just Issued.) 

Preface to the Fifth Edition. 

In preparing the present edition of this work, the general plan nnd arransement of the previous 
editions have been retained, so far as they have been found useful and adapted to the purposes nf 
a text-book for students of medicine. The incessant advance of all the natural and physical 
sciences, never more active than within the last five years, has furnished many valuable aids to 
the special investigations of the physiologist ; and the progress of physiological research, during 
the same period, has required a careful revision of the entire work, and the modification or re- 
arrangement of many of its parts. At this day. nothing is regarded as of any value in natural 
science which is not based upon direct and intelligible observation or experiment: and, accord- 
ingly, the discussion of doubtful or theoretical questions has been avoided, as a general rule, in 
the present volume, while new facts, from whatever source, if fully established, h ive been added 
and incorporated with the results of previous investigation. A number of new illustrations have 
been introduced, and a few of the older ones, which seemed to be no longer useful, have been 
omitted. In all the changes and additions thus made, it has been the aim of the writer to make the 
book, in its present form, a faithful exponent of the actual conditions of physiological science. 
Xew York, October, 1S71. 

In this, the standard text-bock on' Physiology, all that is needed to maintain the favor with which 
it is regarded by the profession, is the author's assurance that it has been thoroughly revised and 
brought up to a level with the advanced science of the day. To accomplish this has required 
some enlargement of the work, but no advance has been made in the price. 

A few notices of previous editions are subjoined. 

It is no disparagement of the many excellent works ; Prof. Dalton's wort has such a well-established 
on physiology, published prior to that of Dalton, to reputation that it does not stand in need of any re- 
say that none of them, either in plan of arrangement commendation. Ever since its first appearance it has 
or clearness of execution, could be compared with his become the highest authority in the English language; 
for the use of students or general practitioners of and that it is able to maintain the enviable position 
medicine. For this pu rpos e bis book has no equal in which it has taken, the rapid exhaustion of the dif- 
tke English language. — Western Journal of Medi- ferent successive editions is sufficient evidence. The 
cine, Nov. 1S67. present edition, which is the fourth, has been tho- 

A capital text-book in everv way. We are. there- roughly revised, and enlarged by the incorporation 
fine, glad to see it in its fourth edition. It has alreadv of a11 the many important advances which have 
been examined at fall length in these columns, so that latel 7 been made in this rapidly progressing science, 
we need not now further advert to it beyond remark- : ~ x - Y - Med - R&C0Tll i Uct - 1o > 15 > b7 - 
ing that hoth revision and enlargement have been As it stands, we esteem it the very best of the phy- 
most judicious.— London Med. Times and Gazette, siologieal text-books for the student, and the most 
Oct. 19, 1S67. concise reference and guide-book for the practitioner. 

No better proof of the value of this admirable — y - T - Med - Journal, Oct. 1S67. 
work could be produced than the fact that it has al- The present edition of this now standard work fully 
ready reached a fourth edition in the short space of sustains the high reputation of its accomplished au- 
eight years. Possessing in an eminent degree the thor. It is not merely a reprint, but has been faith- 
merits of clearness and condensation, and being fully fully revised, and enriched by such additions as the 
brought up to the present level of Physiology, it is progress of physiology has rendered desirable. Taken 
undoubtedly one of the most reliable text-books . as a whole, it is unquestionably the mo>treliable and 
upon this science that could be placed in the hands useful treatise on the subject that has been issued 
of the medical student. — Am. Journal Med Sciences, from the American press. — Chicago Med. Journal, 
Oct. 1867. Sept. 1S67. 



D 



UXGLISOX (EOBLET). 31. D., 

Professor of Institutes of Medicine in Jefferson Medical College, Philadelphia. 

HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and 

extensively modified and enlarged, with five hundred and thirty-two illustrations. In tw 
large and handsomely printed octavo volumes of about 1500 pages, extra cloth. $7 00. 



TEH31AXX(C. G.). 

PHYSIOLOGICAL CHEMISTRY. Translated from the second edi 

tion by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D.. Professor o 
Chemistry in the Medical Department of the University of Pennsylvania, with illustrations 
selected from Funke*s Atlas of Physiological Chemistry, and an Appendix of plates. Com- 
plete in two large and handsome octavo volumes, containing 1200 pages, with nearly two 
hundred illustrations, extra cloth. $6 00. 

T)Y THE SAME AUTHOR. 

MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the 

German, with Notes and Additions, by J. Chestox Morris, M. D., with an Introductory 
Essay on Vital Force, by Professor Samuel Jacksox, M. D., of the University of Pennsyl- 
vania. With illustrations on wood. In one very handsome octavo volume of 336 pages. 
extra cloth. $2 25. 



fTODD [ROBERT B.), 31. D. F.E.S., and T>OW31AX ( TT.), F.R 



,S. 



THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF 

MAN. "With about three hundred large and beautiful illustrations on wood. Complete in 
one large octavo volume of 950 pages, extra cloth. Price $4 75. 



10 



Henry C. Lea's Publications — (Chemistry). 



ATTFIELD {JOHN), Ph.D., 

Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, &c. 

CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL; 

including the Chemistry of the IT. S. Pharmacopoeia. A Manual of the General Principles 
of the Science, and their Application to Medicine and Pharmacy. From the Second and 
Enlarged English Edition, revised by the author. In one handsome royal 12mo. volume 
of about 550 pages ; extra cloth, $2 75 ; leather, $3 25. (Just Issued.) 
It contains a most admirable digest of what is spe- i required at his examinations. — The Pharmaceutical 
dally needed by thf — 



medical student in all that re 
lates to practical chemistry, and constitutes for him 

a sound and useful text-hook on the subject 

We commend it to the notice of every medical, as well 
as pharmaceutical, student. We only regret that we 
had not the book to depend upon in working up the 
subject of practical and pharmaceutical chemistry for 
the. University of London, for which it seems to us 
that it is exactly adapted. This is paying the book a 
high compliment. — The Lancet. 

Dr. Attfield's book is written in a clear and able 
manner; it is a work smi generis &vd without a rival ; 
it will be welcomed, we think, by every reader of the 
'Pharmacopoeia,' and is quite as well suited for the 
medical student as for the pharmacist.— The Chemi- 
cal News. 

A valuable guide to practical medical chemistry, 
and an admirable companion to the "British Phar- 
macopoeia. " It is rare to find so many qualities com- 
bined, and quite curious to note how much valuable 
information finds a mutual interdependence. — Medi- 
cal Times and Gazette. 

It is almost the only book from which the medical 
student can work up the pharmacopceial chemistry 



Journal. 

At page 350 of the current volume of this journal, 
we remarked that " there is a sad dearth of [medical] 
students' text-books in chemistry." Dr. Attfield's 
volume, just published, is rather a new book than a 
second edition of his previous work, and more nearly 
realizes our ideal than any book we have before seen 
on the subject. — The British Medical Journal. 

The introduction of new matter has not destroyed 
the original character of the work, as a treatise on 
pharmaceutical and medical chemistry, but has sim- 
ply extended the foundations of these special depart- 
ments of the science. — The Chemist and Druggist. 

We believe that this manual has been already 
adopted as the class-book by many of the professors 
in the public schools throughout the United Kingdom. 
... In pharmaceutical chemistry applied to the phar- 
macopoeia, we know of no rival. It is, therefore, par- 
ticularly suited to the medical student. — The Medical- 
Press and Circular. 

It in every way fulfils the intention of the author. 
We can strongly recommend it as a most complete 
manual of chemistry, alike useful to the physician 
and pharmaceutist. — Canada Med. Journ., Nov. '70. 







DLING ( WILLIAM), 

Lecturer on Chemistry, at St. Bartholomew's Hospitjl, &c. 

A COURSE OE PRACTICAL CHEMISTRY, arranged for the Use 

of Medical Students. With Illustrations. From the Fourth and Revised London Edition. 

In one neat royal 12mo. volume, extra cloth. $2. (Lately Issued.) 

As a work for the practitioner it cannot be excelled, ganic chemistry, etc. The portions devoted to a dis- 

It is written plainly and concisely, and gives in a very cussion of these subjects are very excellent. In no 

small compass the information required by the busy work can the physician find more that is valuable 

practitioner. It is essentially a work for the physi- and reliable in regard to urine, bile, milk, bone, uri- 

cian, and no one who purchases it will ever regret the nary calculi, tissue composition, etc. The work is 

outlay. In addition to all that is usually given in small, reasonable in price, and well published. — 

connection with inorganic chemistry, there are most Richmond and Louisville Med. Journal, Dec. 1869. 
valuable contributions to toxicology, animal and or- 



jyO WMAN {JOHN E.) , M. D. 

PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited 

by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth 
American, from the fourth and revised English Edition. In one neat volume, royal 12mo., 
pp. 351, with numerous illustrations, extra cloth. $2 25. (Just Issued.) 

The fourth edition of this invaluable text-book of I which have come to light since the previous editioa 
Medical Chemistry was published in England in Octo- was printed. The work is indispensable to every 
ber of the last year. The Editor has brought down J student of medicine or enlightened practitioner. It 
the Handbook to that date, introducing, as far as was is printed in clear type, and the illustrations are 
compatible with the necessary conciseness of such a numei'ous and intelligible. — Boston Med. and Surg. 
work, all the valuable discoveries in the science | Journal. 

OY THE SAME AUTHOR. 

INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING 

ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- 
ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 25. (Just Issued.) 
One of the most complete manuals that has for a 
long time been given to the medical student. — 



Athenaum. 

We regard it as realizing almost everything to be 
desired in an introduction to Practical Chemistry. 



It is by far the best adapted for the Chemical student 
of any that has yet fallen in our way. — British and 
Foreign Medico-Chirurgical Review. 

The best introductory work on the subject with 
which we are acquainted. — Edinburgh Monthly Jour. 



o 



RAHAM [THOMAS], F.R.S. 

THE ELEMENTS OF INORGANIC CHEMISTRY, including the 

Applications of the Science in the Arts. New and much enlarged edition, by Henry 
Watts and Robert Bridges, M. D. Complete in one large and handsome octavo volume, 
of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. 

$5 50. 

with 500 wood 



ENAPP'S TECHNOLOGY ; or Chemistry Applied to 
the Arts, and to Manufactures. With American 
additions, by Prof. Walter fi. Johnson. In two 



very handsome octavo volnm 
engravings, extra cloth, $6 00. 



F 



Henry C. Lea's Publications — {Chemistry, Pharmacy, &c). 11 
OWNES {GEORGE), Ph. D. 



A MAXUAL OF ELEMENTARY CHEMISTRY; Theoretical and 

Practical. With one hundred and ninety-seven illustrations. A new American, from the 
tenth and revised London edition. Edited by Robert Bridges, 3d. D. In one large 
royal 12mo. volume, of about 850 pp., extra cloth, s2 75 ; leather, s3 25. (Just Issued.) 

Some years having elapsed since the appearance of the last American edition, and several 
revisions having been made of the work in England during the interval, it will be found very 
greatly altered, and enlarged by about two hundred and fifty pages, containing nearly one half 
more matter than before. The editors, Mr. Watts and Dr. Bence Jones, have labored sedulously 
to render it worthy in all respects of the very remarkable favor which it has thus far enjoyed, by 
incorporating in it all the most recent investigations and discoveries, in so far as is compatible with 
its design as an elementary test-book. While its distinguishing characteristics have been pre- 
served, various portions have been rewritten, and especial pains have been taken with the 
department of Organic Chemistry in which late researches have accumulated so many new facts 
and have enabled the subject to be systematized and rendered intelligible in a manner formerly 
impossible. As only a few months have elapsed since the work thus passed through the hands 
of Mr. Watts and Dr. Bence Jones, but little has remained to be done by the American editor. 
Such additions as seemed advisable have however been made, and especial care has been taken 
to secure, by the closest scrutiny, the accuracy so essential in a work of this nature. 

Thus fully brought up to a level with the latest advances of scienee, and presented at a price 
within the reach of all, it is hoped that the work will maintain its position as the favorite text- 
book of the medical student. 

This work is so well known that it seems almost l the General Principles of Chemical Philosophy, and 
superfluous for us to speak about it. It has been a the greater part of the organic chemistry, have been 
favorite text-book with medical students for years, rewritten, and the whole work revised in accordance 
ajid its popularity has in no respect diminished, with the recent advances in chemical knowledge. It 
Whenever we have been consulted by medical stu- remains the standard text-book of chemistry. — Dub- 
dents. as has frequently occurred, what treatise on lin Quarterly Journal, Feb. 1S69. 
chemistry they should procure, we have alwavs re- I m , . , _, , , , 

commended Fownes'. for we regarded it as the* best. i Taere 1S probably not a student of chemistry in this 
There is no work that combines so manv excellen- country to whom the admirable manual of the late 
ces. It is of convenient size, not prolix, of plain Professor Fownes is unknown It has achieved a 
perspicuous diction, contains all the most recent success which we believe is entirely without a paral- 
discoveries, and is of moderate price.— Cincinnati lei among scientific text-books m our language. This 
Med. Repertory Aug. 1S69. success has arisen from the fact that there is no En- 

'..','.' , .,,.,-, glish work on chemistry which combines so many 

Large additions have been made, especially m the | xcellences . f convenient size, of attractive form. 
department of organic chemistry, and we know of no c!ear and concige ia dicti well mustrated and of 
other work that has greater claims on the physician, moderate price it wou]d seem that every requisite 
pnarmaceutist, or student, than this We cheenully for a student's hand-book has been attained. The 
recommend it as the best text-book on elementary niath edition was published under the joint editor- 
chemistry, and bespeak for it the caretul attention sM of Dr Bence Jones and Dr Hofmann . the ne ^ 
ot students oi pharmacy— CAieatfo Pharmacist, Aug. ; oae has been superintended through the press by Dr. 
lt>69 - I Bence Jones and Mr. Henry Watts. It is not too 

The American reprint of the tenth revised and cor- i much to say that it could not possibly have been in 
rected English edition is now issued, and represents \ better hands. There is no one in England who can 
the present condition of the science. Xo comments j compare with Mr. Watts ia experience as a compiler 
are necessary to insure it a favorable reception at ! in chemical literature, aud we have much pleasure 
the hands of practitioners and students. — Boston , in recording the fact that his reputation is well sns- 
Med. and Surg. Journal, Aug. 12, 1S69. tained by this, his last undertaking. — The Chemical 



It will continue, as heretofore, to hold the first rank 
as a text-book for students of medicine. — Chicago 
Med. Examiner, Aug. 1S69. 

This work, long the recognized Manual of Chemistry, 
appears as a tenth edition, under the able editorship 
of Bence Jones and Henry Watts. The chapter on l Indian Medical Gazette, Jan. 1, 1S69. 



News, Feb. li 

Here is a new edition which has been long watched 
for by eager teachers of chemistry. In its new garb, 
and under the editorship of Mr. Watts, it has resumed 
its old place as the most successful of text-books. — 



URANDE {WM. T.), D.C.L., and JIAYLOR {ALFRED S.), M.D., F.R.S. 
CHEMISTRY. Second American edition, thoroughly revised by Dr. 

Taylor. In one handsome 8vo. volume of 764 pages, extra cloth, $5 00 ; leather, $6 00. 
From Dr. Taylor's Preface. 
"The revision of the second edition, in consequence of the death of my lamented colleague, 
has devolved entirely upon myself. Every chapter, and indeed every page, has been revised, 
and numerous additions made in all parts of the volume. These additions have been restricted 
chiefly to subjects having some practical interest, and they have been made as concise as possible, 
in order to keep the book within those limits which may retain for it the character of a Student's 
Manual " — London, June 29, 1867. 

A book that has already so established a reputa- of information with the most sparing use of technical 

tion, as has Brande and Taylor's Chemistry, can terms and phraseology, so as to furnish the reader, 

hardly need a notice, save to mention the additions "whether a student of medicine, or a man of the 

aud improvements of the edition. Doubtless the world, with a plain introduction to the science and 

work will long remain a favorite text-book in the practice of chemistry." — Journal of Applied Chem- 

schools, as well as a convenient book of reference for istry, Oct. 1S67. 

all.-X Y. Medical Gazette, Oct, 12, 1S67. TMs second American edition of an excellent trea- 

For this reason we hail with delight the republica- tise on chemical science is not a mere republication 

tion, in a form which will meet with general approval from the English press, but is a revision and en- 

and command public attention, of this really valua- largement of the original, under the supervision of 

ble standard work on chemistry — more particularly the surviving author, Dr. Taylor. The favorable 

as it has been adapted with such care to the wants of opinion expressed on the publication of the former 

the general public. The well known scholarship of edition of this work is fully sustained by the present 

its authors, and their extensive researches for many revision, in which Dr. T. has increased the size of 

years in experimental chemistry, have been long an- the volume, by|an addition of sixty-eight pages. — Am. 

preciated in the scientific world, but in this work they Journ. lied. Sciences, Oct. 1S67. 

iuive been careful to give the largest possible amount ] 



12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics). 



pARRlSH {EDWARD), 

Professor of Materia Medica in the Philadelphia College of Pharmacy . 

A TREATISE <M PHARMACY. Designed as a Text-Book for the 

Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and 
Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 
pages, with several hundred illustrations, extra cloth. $5 00; leather, $6 00. 
The immense amount of practical information condensed in this volume may be estimated from 
the fact that the Index contains about 4700 items. Under the head of Acids there are 312 refer- 
ences ; under Emplastrum, 36; Extracts, 159 ; Lozenges, 25; Mixtures, 55; Pills, 58; Syrups, 
131; Tinctures, 138; Unguentum, 57, &c. 



We have examined this large volume with a good 
deal of cave, and find that the author has completely 
exhausted the subject upon which he treats ; a more 
complete work, we think, it would be impossible to 
find. To the student of pharmacy the work is indis- 
pensable ; indeed, so far as we know, it is the only one 
of its kind in existence, and even to the physician or 
medical student who can spare five dollars to pur- 
chase it, we feel sure the practical information he 
will obtain will more than compensate him for the 
outlay. — Canada, Med. Journal, Nov. 1864. 

The medical student and the practising physician 
will find the volume of inestimable worth for study 
and reference. — San Francisco Med. Press, July, 
1S61. 

When we say that this book is in some respects 
the best which has been published on the subject in 
the English language for a great many years, we do 



not wish it to be understood as very extravagant 
praise. In truth, it is not so much the best as the 
only book. — The London Chemical News. 

An attempt to furnish anything like an analysis of 
Parrish's very valuable and elaborate Treatise on 
Practical Pharmacy would require more space than 
we have at our disposal. This, however, is not so 
much a matter of regret, inasmuch as it would be 
difficult to think of any point, however minute and 
apparently trivial, connected with the manipulation 
>f pharmaceutic substances or appliances which has 
not been clearly and carefully discussed in this vol- 
ume. Want of space prevents our enlarging farther 
on this valuable work, and we must conclude by a 
simple expression of our hearty appreciation of its 
merits. — Dublin Quarterly Jour, of Medical Science 
August, 186-4. 



CI TILL E {ALFRED), M.D., 

U Professor of Theory and Practice of Medicine in the University of Penna. 

THERAPEUTICS AND MATERIA MEDICA; a Systematic Treatise 

on the Action and Uses of Medicinal Agents, including their Description and History. 

Third edition, revised and enlarged. In two large and handsome octavo volumes of about 

extra cloth, $10 , 

abi-oad its reputation as a standard treatise on Materia 
Medica is securely established. It is second to no 
work on the subject in the English tongue, and, in- 
deed, is decidedly superior, in some respects, to any 
other. — Pacific Med. and Surg Journal, July, 1868. 

Still6's Therapeutics is incomparably the best work 
on the subject.— N. Y. Med. Gazette, Sept. 26, 186S. 

Dr. Still^'s work is becoming the best known of any 
of our treatises on Materia Medica. . . . One of the 
most valuable works in the language on the subjects 
of which it treats.— N. Y. Med. Journal, Oct. 1868. 

The rapid exhaustion of two editions of Prof. Stille'a 
scholarly work, and the consequent necessity for a 
third edition, is sufficient evidence of the high esti- 
mate placed upon it by the profession. It is no exag- 
geration to say that there is no superior work upon 
the subject in the English language. The present 
edition is fully up to the most recent advance in the 
science and art of therapeutics. — Leavenworth Medi- 
cal Herald, Aug. 1S6S. 

The work of Prof. Stille" has rapidly taken a high 
place in professional esteem, and to say that a third 
edition is demanded and now appears before us, suffi- 
ciently attests the firm position this treatise has made 
for itself. As a work of great research, and scholar- 
ship, it is safe to say we have nothing superior. It is 
exceedingly full, and the busy practitioner will find 
ample suggestions upon almost every important point 
of therapeutics. — Cincinnati Lanett, Aug. 1S68. 



1700 pages, extra cloth, $10 ; leather, $12 

Dr. Stille's splendid work on therapeutics and ma- 
teria medica.— London Med. Times, April 8, 1865. 

Dr. Stille' stands to-day one of the best and most 
honored representatives at home and abroad, of Ame- 
rican medicine ; and these volumes, a library in them- 
selves, a treasure-house for every studious physician, 
assure his fame even had he done nothing more. — The 
Western Journal of Medicine, Dec. 1868. 

We regard this work as the best one on Materia 
Medica in the Euglish language, and as such it de- 
serves the favor it has received. — Am. Joum. Medi- 
cal Sciences, July 1868. 

We need not dwell on the merits of the third edition 
of this magnificently conceived work. It is the work 
on Materia Medica, in which Therapeutics are prima- 
rily considered — ihe mere natural history of drugs 
being briefly disposed of. To medical practitioners 
this is a very valuable conception. It is wonderful 
how much of the riches of the literature of Materia 
Medica has been condensed into this book. The refer- 
ences alone would make it worth possessing. But it 
is not a mere compilation. The writer exercises a 
good judgment of his own on the great doctrines and 
points of Therapeutics. For purposes of practice, 
Stille's book is almost unique as a repertory of in- 
formation, empirical and scientific, on the actions and 
uses of medicines. — London Lancet, Oct. 31, 1S68. 

Through the former editions, the professional world 
is well acquainted with this work. At home and 



QRIFFITH {ROBERT E.), 31 D. 



A UNIVERSAL FORMULARY, Containing the Methods of Pre- 

paring and Administering Officinal and other Medicines. The whole adapted to Physicians 
and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by 
Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of 
Pharmacy. In one large and handsome octavo volume of 650 pages, double-columns. 
Extra cloth, $4 00; leather, $5 00. 
Three complete and extended Indexes render the work especially adapted for immediate consul- 
tation. One, of Diseases and their Remedies, presents under the head of each disease the 
remedial agents which have been usefully exhibited in it, with reference to the formulas containing 
them — while another of Pharmaceutical and Botanical Names, and a very thorough General 
Index afford the means of obtaining at once any information desired. The Formulary itself is 
arranged alphabetically, under the heads of the leading constituents of the prescriptions. 
We know of none in our language, or any other, so comprehensive in its details. — London Lancet. 
One of the most complete works of the kind in any language. — Edinburgh Med. Journal. 
We are not cognizant of the existence of a parallel work. — London Med. Gazette. 



Henhy C. Lea's Publications — {Mat. Med. and Therapeutics). 13 

pEREIRA (JONATHAN), M.D., F.R.S. and L.S. 

MATERIA MEDICA AND THERAPEUTICS; being an Abridg- 

ment of the late Dr. Pereira's Elements of Materia Mediea, arranged in conformity with 
the British Pharmacopoeia, and adopted to the use of Medical Practitioners, Chemists and 
Druggists, Medical and Pharmaceutical Students, &c. By F. J. Farre, M.D., Senior 
Physician to St. Bartholomew's Hospital, and London Editor of the British Pharmacopoeia; 
assisted by Robert Bentley, M.R.C.S., Professor of Materia Mediea and Botany to the 
Pharmaceutical Society of Great Britain; and by Robert Warington, F.R.S. , Chemical 
Operator to the Society of Apothecaries. With numerous additions and references to the 
United States Pharmacopoeia, by Horatio C. Wood, M.D., Professor of Botany in the 
University of Pennsylvania. In one large and handsome octavo volume of 1040 closely 
printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. 



The task of the American editor has evidently been 
mo sinecure, for not only has he given to us all that 
is contained in the abridgment useful for our pur- 
poses, but by a careful and judicious embodiment of 
over a hundred new remedies has increased the size 
of the former work fully one-third, besides adding 
many new illustrations, some of which are original. 
We unhesitatingly say that by so doing he has pro- 
portionately increased the value, not only of the con- 
densed edition, but has extended the applicability of 
the great original, and has placed his medical coun- 
trymen under lasting obligations to him. The Ame- 
rican physician now has all that is needed in the 
shape of a complete treatise on materia mediea, and 
the medical student has a text-book which, for prac- 
tical utility and intrinsic worth, stands unparalleled. 
Although of considerable size, it is none too large for 
the purposes for which it has been intended , and every 
medical man should, in justice to himself, spare a 
place for it upon his book-shelf, resting assured that 
the more be consults it the better he will be satisfied 
of *ts excellence. — N. Y. Med. Record, Nov. 15, 1836. 

Et will fill a place which no other work can occupy 
in the library of the physician, student, and apothe- 
cary. — Boston Med. and Surg. Journal, Nov. 8, 1866. 

Of the many works on Materia Mediea which have 
appeared since the issuing of the British Pharmaco- 



poeia, none will be more acceptable to the student 
and practitioner than the present. Pereira's Materia 
Mediea bad long ago asserted for itself the position of 
being the most complete work on the subject in the 
English language. But its very completeness stood 
in the way of its success. Except in the way of refer- 
ence, or to those who made a special study of Materia 
Mediea, Dr. Pereira's work was too full, and its pe- 
rusal required an amount of time which few had at 
their disposal. Dr. Farre has very judiciously availed 
himself of the opportunity of the publication of the 
new Pharmacopoeia, by bringing out an abridged edi- 
tion of the great work. This edition of Pereira is by 
no means a mere abridged re-issue, but contains ma- 
ny improvements, both iu the descriptive and thera- 
peutical departments. We can recommend it as a 
very excellent and reliable text-book. — Edinburgh 
Med. Journal, February, 1866. 

The reader cannot fail to be impressed, at a glance, 
with the exceeding value of this work as a compend 
of nearly all useful knowledge on the materia mediea. 
We are greatly indebted to Professor Wood for his 
adaptation of it to our meridian. Without his emen- 
dations and additions it would lose much of its value 
to the American student. With them it is an Ameri- 
can book. — Pacific Medical and Surgical Journal, 
December 3 1866. 



PLLIS {BENJAMIN), M.D. 

THE MEDICAL FORMULARY: being a Collection of Prescriptions 

derived from the writings and practice of mnny of the most eminent physicians of America 
and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The 
whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- 
tion, carefully revised and much improved by Albert H. Smith, M. D. In one volume 8vo. 
of 376 pages, extra cloth, $3 00. {Lately Published.) 
This work has remained for some time out of print, owing to the anxious care with which the 
Editor has sought to render the present edition worthy a continuance of the very remarkable 
favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- 
lously endeavored to introduce in it all new preparations and combinations deserving of confidence, 
besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation 
of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic 
injection, the administration of anaesthetics, &c. &a. To accommodate these numerous additions, 
be has omitted much which the advance of science has rendered obsolete or of minor importance, 
notwithstanding which the volume has been increased by more than thirty pages. A new feature 
will be found in a copious Index of Diseases and their remedies, which cannot but increase the 
value of the work as a suggestive book of reference for the working practitioner. Every precaution 
has been taken to secure the typographical accuracy so necessary in a work of this nature, and it 
is hoped that the new edition will fully maintain the position which " Ellis' Formulary''' has 
long occupied. 



PARSON [JOSEPH], M.D., 

%J Professor of Materia Mediea and Pharmacy in the University of Pennsylvania, &c. 

SYNOPSIS OF THE COURSE OF LECTURES OX MATERIA 

MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three 
Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, 
$3 00. 



EUNGLISON'S NEW REMEDIES, WITH FORMULAE 
FOR THEIR PREPARATION AND ADMINISTRA- 
TION. Seventh edition, with extensive additions. 
One vol. Svo., pp. 770; extra cloth. $4 00. 

ROTLE'S MATERIA MEDICA AND THERAPEU- 
TICS. Edited by Joseph Carson, M. D. With 
ninety-eight illustrations. 1 vol. Svo., pp. 700, ex- 
tra cloth. $3 00. 

CHRISTISON'S DISPENSATORY. With copious ad- 
ditions., and 213 large wood-engravings. By R 



Eglesfeld Griffith, M.D. One vol. Svo., pp. lOOO; 
extra cloth. $4 00. 

CARPENTER'S PRIZE ESSAY ON THE USE OF 
Alcoholic Liquors in Health and Disease. New 
edition, with a Preface by D. F. Gondie. M.D., and 
explanations of scientific words. In one neat 1 2nio. 
vohime, pp. 178, extra cloth. 60 cents. 

De JONGH ON THE THREE KINDS OF COD-LIVER 
Oil, with their Chemical and Therapeutic Pro- 
perties. 1 vol. 12mo., cloth. 75 cents. 



14 



Henry C. Lea's Publications — (Pathology, &c.) 



riREEN (T. HENRY), M.D., 

Lecturer on Pathology and Morbid Anatomy at Charing-Cross Hospital Medical School. 

PATHOLOGY AJNfD MORBID ANATOMY. With numerous Illus- 

trations on Wood. In one very handsome octavo volume of over 250 pages, extra cloth, 
$2 50. {Just Issued.) 
The scope and object of this volume can be gathered from the following condensed 

SUMMARY OF CONTENTS. 

Introduction. Chapter I. The "Cell." II. Nutrition Arrested. III. Nutrition Impaired. 
IV. Fatty Degeneration. V. Mucoid and Colloid Degeneration. VI. Fatty Infiltration. VII. 
Amyloid Degeneration. VIII. Calcareous Degeneration. IX. Pigmentary Degeneration. X. 
Nutrition Increased. XI. New Formations. XII. The Fibromata. XIII. The Sarcomata. 
XIV. The Gummata. XV. The Myxomata. XVI. The Lipomata. XVII. The Enchondromata. 
XVril. The Osteomata. XIX. The Lymphomata. XX. Tubercle. XXI. The Papillomata. 
XXII. The Adenomata. XXIII. The Carcinomata. XXIV. The Myomata, Neuromata, and 
Angeomata. XXV. Cysts. XXVI. Inflammation. XXVII. Inflammation of Non-Vascular 
Tissues. XXVIII. Inflammation of Vascular Connective Tissues. XXIX. Inflammation of 
Bloodvessels and Heart. XXX. Inflammation of Lymphatic Structures. XXXI. Inflammation 
of Mucous Membranes. XXXII. Inflammation of Serous Membranes. XXXIII. Inflammation 
of the Liver. XXXIV. Inflammation of the Kidney. XXXV. Inflammation of the Ltmgs. 
XXXVI. Inflammation of Brain and Spinal Cord. XXXVII. Changes in the Blood and Circu- 
lation. XXXVIII. Thrombosis. XXXIX. Embolism. 

We have been very much pleased l»y our perusal of j information is up to the day, well and compactly ar- 
this little volume. It is the only one of the kind with ranged, without being at all scanty. — London Lan- 
which we are acquainted, and practitioners as well cet, Oct. 7, 1871. 
as students will find it a very useful guide ; for the | 



G 



ROSS (SAMUEL D.), M. D., 

Professor of Surgery in the Jefferson Medical College of Philadelphia. 

ELEMENTS OP PATHOLOGICAL ANATOMY. 



Third edition, 



thoroughly revised and greatly improved. In one large and very handsome octavo volume 
of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a 
large number are from original drawings ; extra cloth. $4 00. 



TONES (G. HANDFIELD), F.R.S., and SIEVEKING (ED. H.)] M.D., 

*-J Assistant Physicians and Lecturers in St. Mary's Hospital. 

A MANUAL OF PATHOLOGICAL ANATOMY. First American 

edition, revised. With three hundred and ninety-seven handsome wood engravings. In 
one large and beautifully printed octavo volume of nearly 750 pages, extra cloth, $3 50. 



JDARCLAY (A. W.), M. D. 

A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the 

Signs and Symptoms of Disease. Third American from the second and revised London 
edition. In one neat octavo volume of 451 pages, extra cloth. $3 50. 

JXflLLIAMS .(CHARLES J. B.), M.D., 

* ' Professor of Clinical Medicine in University College, London. 

PRINCIPLES OF MEDICINE. An Elementary Yiew of the Causes, 

Nature, Treatment, Diagnosis, and Prognosis of Disease ; with brief remarks on Hygienic*, 
or the preservation of health. A new American, from the third and revised London edition. 
In one octavo volume of about 500 pages, extra cloth. $3 50. 

GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. 

Translated, with Notes and Additions, by Joseph 

Leidy, M. D. In one volume, very large imperial 

quarto, with 320 copper-plate figures, plain and 

colored, extra cloth. $1 00. 
SIMON'S GENERAL PATHOLOGY, as conducive to 

the Establishment of Rational Principles for tho 

Prevention and Cure of Disease. In one octavo 

volume of 212 pages, extra cloth. $1 25. 
SOLLY ON THE HUMAN BRAIN ; its Structure, Phy- 
siology, and Diseases. From the Second and much 

enlarged London edition. In one octavo volume 

500 pages, with 120 wood-cuts; extra cloth. $2 50. 
LA ROCHE ON YELLOW FEVER, considered in its 

Historical, Pathological, Etiological, and Therapeu- 



tical Relations. In two large and handsome octavo 
volumes, of nearly 1500 pages, extra cloth, $7 00. 

HOLLAND'S MEDICAL NOTES ANI REFLEC- 
TIONS. 1 vol. Svo., pp. 500, extra cloth. $3 50 

WHATTO OBSERVE AT THE BEDSIDE AND AFTER 
Death in Medical Cases. Published under the 
authority of the London Society for Medical Obser- 
vation. From the second London edition. 1 vol. 
royal 12mo., extra cloth. $1 00. 

LAYCOCK'S LECTURES ON THE PRINCIPLES 
and Methods of Medical Observation and Re- 
search. For the use of advanced students and 
junior practitioners. In one very neat royal 12mo. 
volume, extra cloth. $1 00. 



D 



DNGLISON, FORBES, TWEEDIE, AND CONOLLY. 

THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising 

Treatises on the Nature nnd Treatment of Diseases, Materia Medica and Therapeutics, 
Diseases of Women and Children, Medical Jurisprudence, &c. &a. In four large super-royal 
octavo volumes, of 3254 double-columned pages, strongly and handsomely bound in leather, 
$15; extra cloth, $J1. 

*=** This work contains no less than four hundred and eighteen distinct treatises, contributed 
by sixty-eight distinguished physicians. 



Henry C. Lea's Publications — {Practice of Medicine). 



15 



TjlLINT (AUSTIX), 31. D., 

-*- Professor of the Principles and Practice of Medicine in Bellevue Med. College, N. T. 

A TREATISE OX THE PRINCIPLES AXD PRACTICE OF 

MEDICINE ; designed for the use of Students and Practitioners of Medicine. Tbird 

edition, revised and enlarged. In one large and closely printed octavo volume of 1002 

pages ; handsome extra cloth, $6 00 ; or strongly bound in leather, with raised bands, $7 00. 

(Lately Published.) 

By common consent of the English and American medical press, this work has been assigned 

to the highest position as a complete and compendious text-book on the most advanced condition 

of medical science. At the very moderate price at which it is offered it will be found one of the 

cheapest volumes now before the profession. 



Admirable and unequalled. 
Medicine, Nov. 1S69. 



Western Journal of 



Dr. Flint's work, though claiming no higher title 
fchan that of a text-book, is really more. He is a man 
»f large clinical experience, and his book is full of 
*uch masterly descriptions of disease as can only be 
drawn by a man intimately acquainted with their 
various forms. It is not so long since we had the 
pleasure of reviewing his first edition, and we recog- 
nize a great improvement, especially in the general 
part of the work. It is a work which we can cordially 
recommend to our readers as fully abreast of the sci- 
ence of the day. — Edinburgh Med. Journal, Oct. '69. 

One of the best works of the kind for the practi- 
tioner, and the most convenient of all for the student. 
— Am. Journ. Med. Sciences, Jan. 1S69. 

This work, which stands pre-eminently as the ad- 
vance standard of medical science up to the present 
time in the practice of medicine, has for its author 
one who is well and widely known as one of the 
leading practitioners of this continent. In fact, it is 
seldom that any work is ever issued from the press 
more deserving of universal recommendation. — Do- 
minion Med. Journal, May, 1S69. 

The third edition of this most excellent book scarce- 
ly needs any commendation from as. The volume, 
*,s it stands now, is really a marvel : first of all, it is 
excellently printed and bound — and we encounter 
that luxury of America, the ready-cut pages, which 
the Yankees are 'cute enough to insist upon — nor are 
these by any means trifles ; but the contents of the 
book are astonishing. Not only is it wonderful that 
any one man can have grasped in his mind the whole 



Much valuable matter has been added, and by mak- 
ing the type smaller, the bulk of the volume is not 
much increased. The weak point in many American 
works is pathology, but Dr. Flint has taken peculiar 
pains on this .point, greatly to the value of the book. 
— London Med. Times and. Gazette, Feb. 6, 1869. 

Published in 1866, this valuable book of Dr. Flint's 
has in two years exhausted two editions, and now 
we gladly announce a third. We say we gladly an- 
nounce it, because we are proud of it as a national 
representative work of not only American, but of 
cosmopolitan medicine. In it the practiceof medicine 
is young and philosophical, based on reason and com- 
mon sense, and as such, we hope it will be at the 
right hand of every practitionerof this vast continent. 
— California Medical Gazette, March, 1S69. 

Considering the large number of valuable works in 
the practice of medicine, already before the profes- 
sion, the marked favor with which this has been re- 
ceived, necessitating a third edition in the short space 
of two years, indicates unmistakably that it is a work 
of more than ordinary excellence, and must be accept- 
ed as evidence that it has largely fulfilled the object 
for which the author intended it. A marked feature 
in the work, and one which particularly adapts it for 
the use of students as a text-book, and certainly ren- 
ders it none the less valuable to the busy practitioner 
as a work of reference, is brevity and simplicity 
The present edition has been thoroughly revised, and 
much new matter incorporated, derived, as the author 
informs us, both from his own clinical studies, and 
from the latest contributions to medical literature, 
thus bringing it fully up with the most recent ad- 
vances of the science, and greatly enhancing its prac 



scope of medicine with that vigor which Dr. Flint j tical utility; while, by a slight modification of it 



shows, but the condensed yet clear way in which 
this is done is a perfect literary triumph Dr. Flint 
is pre-eminently one of the strong men, whose right 
to do this kind of thing is well admitted ; and we say 
no more than the truth when we affirm that he is 
very nearly the only living man that could do it with 
such results as the volume before us.— The Lond.on 
Practitioner, March, 1S69. 

This is in some respeets the best text-book of medi- 
cine in our language, and it is highly appreciated on 
the other side of the Atlantic, inasmuch as the first 
edition was exhausted in a few months. The second 
edition was littie more than a reprint, but the present 
has, as the author says, been thoroughly revised. 



typographical arrangement, the additions have been 
accommodated without materially increasing its 
bulk.— St. Louis Med. Archives, Feb. 1869. 

If there be among our readers any who are not fa- 
miliar with the treatise before us, we shall do them 
a service in persuading them to repair their omission 
forthwith. Combining to a rare degree the highest 
scientific attainments with the .most practical com- 
mon sense, and the closest habits of observation, the 
author has given us a volume which not only sets 
forth the results of the latest investigations of other 
laborers, but contains more original views than any 
other single work upon this well-worn theme within 
our knowledge.— N. Y. Med. Gazette, Feb. 27, 1869. 



BARLOWS MANUAL OF THE PPvACTICE OF 
MEDICINE. With Additions bv D. F. Condie, 
M. D. 1 vol. 8vo., pp. 600, cloth." %1 50. 



TODD'S CLINICAL LECTURES ON CERTAIN ACUTE 
Diseases. In one neat octavo volume, of 320 pages, 
extra cloth. $2 50. 



PA YY (F. W.), 31. />.. F. R. &, 
Senior Asst. Physician to and Lecturer on Physiology, at Guy's Hospital, &c. 

A TREATISE OX THE FUXCTIOX OF DIGESTIOX; its Disor- 

ders and their Treatment. From the second London edition. In one handsome volume, 
small octavo, extra cloth, $2 00. (Lately Published.) 
The work before us is one which deserves a wide treatise, and sufficiently exhaustive for all practical 
circulation. We know of no better guide to the study 
of digestion and its disorders. — St. Louis Med. and 
Surg. Journal, July 10, 1869. 

A thoroughly good book, being a careful systematic 



purposes. — Lf-aw/ucorth Med. Herald, July, 1S69. 

A very valuable work on the subject of which it 
treats. Small, yet it is full of valuable information. 
— Cincinnati Med. Repertory, June, 1869. 



B 



RINTON {WILLIA3D, M.D., F.R.S. 

LECTURES OX THE DISEASES OF THE STOMACH; with an 

Introduction on its Anatomy and Physiology. From the second and enlarged London edi- 
tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, 
extra cloth. $3 25. 



16 



Henry C. Lea's Publications — (Practice of Medicine). 



fTARTSHORNE {HENRY), M.D., 

JLJL Professor of Hygiene in the University of Pennsylvania. 

ESSENTIALS OF THE PRINCIPLES AND PRACTICE OE MEDI- 

CINE. A handy-book for Students and Practitioners. Third edition, revised and im- 
proved. In one handsome royal J2mo. volume of 487 pages, clearly printed on small type, 
cloth, $2 38; half bound, $2 63. (Now Beady.) 
The very remarkable favor which has been bestowed upon this work, as manifested in the ex- 
haustion of two large editions within four years, shows that it has successfully supplied a want 
lelt by both student and practitioner of a volume which at a moderate priee and in a convenient 
size should afford a clear and compact view of the most modern teachings in medical practice. 
In preparing the work for a third edition, the author has sought to maintain its character by very 
numerous additions, bringing it fully up to the science of the day, but so concisely framed that 
the size of the volume is increased only by thirty or forty pages. The extent of the new informa- 
tion thus introduced may be estimated by the fact that there have been two hundred and sixty 
separate additions made to the text, containing references to one hundred and eighty new authors. 

This little epitome of medical knowledge has al- I mulcts are appended, intended as examples merely, 
ready been noticed hy us. It is a vade mecnm of not as guides, for unthinking practitioners. A com- 
value, including in a short space most of -what is es- j plete index facilitates the use oi this little volume, in 
sential in the science and practice of medicine. The i which all important remedies lately introduced, such 
third edition is well up to the present day in the ! as chloral hydrate and carbolic acid, have received 
modern methods of treatment, audiu the use of newly [ their full share of attention. — Am. Joum. of Pharrn., 
discovered drugs. — Boston Med. and Surg. Journal, Nov. 1S71. 
Oct. 19, 1S71. 

Certainly very few volumes contain so much pre- I f' ro *edici 
else information within so small a compass.-iV. Y. j . pract i tioner foi . easy reference, and especially to 
Med. Jmirnal, Isov. 1S71. | £ pdeBtia attendance upon lecture*, whose tim. - 

The diseases are conveniently classified; symptoms, too much occupied with many studies, to consult the 
causation, diagnosis, prognosis, and treatment are I larger works. Such a work must always be in great 
carefully considered, the whole being marked by | demand. — Cincinnati Med. Repertory, '.Nov. 1571, 
briefness, but clearness of expression. Over 2o0 for- j 



, and will be found most valuable to the 

the 



WATSON (THOMAS), M. D. y frc. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF 

PHYSIC. Delivered at King's College, London. A new American, from the Fifth re- 
vised and enlarged English edition. Edited, with additions, and several hundred illus- 
trations, by Henry Hartshorne, M.D., Professor of Hygiene in the University of Penn- 
sylvania, In two large and handsome octavo volumes. (Shortly.) 
With the assistance of Professor George Johnson, his successor in the chair of Practice of Medi- 
cine in King's College, the author has thoroughly revised this work, and has sought to bring H 
on a level with the most advanced condition of the ,-ubject. As he himself remarks : " Consider- 
ing the rapid advance of medical science during the last fourteen years, the present edition would 
be worthless, if it did not differ much from the last" — but in the extensive alterations and addi- 
tions that have been introduced, the effort of the author has been to retain the lucid and collo- 
quial style of the lecture-room, which has made the work so deservedly popular with all classes 
of the profession. Notwithstanding these changes, there are some subjects on which the American 
reader might reasonably expect more detailed information than has been thought requisite in 
England, and these deficiencies the editor has endeavored to supply. 

The large size to which the work has grown seems to render.it necessary to print it in two vol- 
umes, in place of one, as in the last American edition. It is therefore presented in that shape, 
handsomely printed, at a very reasonable price, and it is hoped that it will fully maintain the 
position everywhere hitherto accorded to it, of the standard and classical representative of Eng- 
lish practical medicine. 



At length, after many months of expectation, we 
have the satisfaction of finding ourselves this week in 
possession of a revised and enlarged edition of Sir 
Thomas Watson's celebrated Lectures It is a sub- 
ject for congratulation and for thankfulness that Sir 
Thomas Watson, during a period of comparative lei- 
sure, after a long, laborious, and most honorable pro- 
essional career, while retaining full possession of his 
high mental faculties, should have employed the op- 
portunity to submit his Lectures to a more thorough 



revision than was possible during the earlier and 
busier period of his life. Carefully passing in review 
some of the most intricate and important pathological 
and practical questious, trie results of his clear insight 
and his calm judgment are now recorded for the bene- 
fit of mankind, in language which, for precision, vigor, 
and classical elegance, has rarely been equalled, and 
never surpassed The revisiou has evidently been 
most carefully done, and the results appear in almost 
every page.— Brit. Med. Jouni., Oct, 14, 1S71. 



S1HAMBERS [T. K.), if. D., 

V^ Consulting Physician to St. Mary's Hospital, London, Ac. 

THE INDIGESTIONS ; or, Diseases of the Digestive Organs Functionally 

Treated. Third and revised Edition. In one handsome octavo volume of 3S3 pages, extra 

cloth. $3 00. (Lately Published.) 

merit, we know of no more desirable acquisition to 
a physician's library than the book before us. 1 



So very large a proportion of the patients applying 
to every general practitioner suffer from some form 
of indigestion, that whatever aids him in their man- 
agement directly "puts money in his purse," and in- 
directly does more than anything else to advance his 
reputation with the public. From this purely mate- 
rial point of view, setting aside its higher claims to 



who should commit its contents to his memory would 
tiud its price an investment of capital that retnrued 
him a most usurious rate of interest. — N. Y. Medical 
Gazette, Jan 28. 1S71. 



J)Y THE SAME AUTHOR. (Just Issued.) 

RESTORATIVE MEDICINE. An Harveian Annual Oration, deliv- 
ered at the Royal College of Physicians, London, on June 24, 1871. "With Two Sequels. 
In one very handsome volume, small 12mo., extra cloth, $1 00. 



Henry C. Lea's Publications — (Diseases of Lungs and Heart). 17 



JPLINT {AUSTIN), M.D., 

-*■ Professor of the Principles and Practice of Medicine in Bellevue Hospital Med. College, N. Y. 

A PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY, 

AND TREATMENT OF DISEASES OF THE HEART. Second revised and enlarged 

edition. In one octavo volume of 550 pages, with a plate, extra cloth, $4. {Just Issued.) 

The author has sedulously improved the opportunity afforded him of revising this work. Portions 

of it have been rewritten, and the whole brought up to a level with the most advanced condition of 

science. It must therefore continue to maintain its position as the standard treatise on the subject. 



Dr. Flint chose a difficult subject for his researches, 
and has shown remarkable powers of observation 
and reflection, as well as great industry, in his treat- 
ment of it. His book must be considered the fullest 
and clearest practical treatise on those subjects, and 
should be in the hands of all practitioners and stu- 
dents. It is a credit to American medical literature. 
— Arner. Journ. of the Med. Sciences, July, 1S60. 

We question the fact of any recent American author 
in our profession being more extensively known, or 
more deservedly esteemed in this country than Dr. 
Flint. We willingly acknowledge his success, more 
particularly in the volume on diseases of the heart, 
in making an extended personal clinical study avail- 



able for purposes of illustration, in connection with 
cases which have been reported by other trustworthy 
observers. — Brit, and For. Med.-Ohirurg. Review. 

In regard to the merits of the work, we have no 
hesitation in pronouncing it full, accurate, and judi- 
cious. Considering the present state of science, such 
a work was much needed. It should be in the hands 
of every practitioner. — Chicago Med. Journ. 

With more than pleasure do we hail the advent of 
this work, for it fills a wide gap on the list of text- 
books for our schools, and is, for the practitioner, the 
most valuable practical work of its kind. — N. 0. Med. 
News. 



JDT THE SAME AUTHOR. 

A PRACTICAL TREATISE ON THE PHYSICAL EXPLORA- 
TION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AFFECTING THE 
RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume 
of 595 pages, extra cloth, $4 50. 

which pervades his whole work lend an additional 
force to its thoroughly practical character, which 
cannot fail to obtain for it a place as a standard work 
on diseases of the respiratory system. — London 
Lancet, Jan. 19, 1867. 

This is an admirable book. Excellent in detail and 
execution, nothing better could be desired by the 
practitioner. Dr. Flint enriches his subject with 
much solid and not a little original observation.— 
Ranking'' s Abstract, Jan. 1867. 



Dr. Flint's treatise is one of the most trustworthy 
guides which he can consult. The style is clear and 
distinct, and is also concise, being free from that tend- 
ency to over-refinement and unnecessary minuteness 
which characterizes many works on the same sub- 
ject. — Dublin Medical Press, Feb. 6, 1867. 

The chapter on Phthisis is replete with interest ; 
and his remarks on the diagnosis, especially in the 
early stages, are remarkable for their acumen and 
great practical value. Dr. Flint's style is clear and 
elegant, and the tone of freshness and originality 



F 



ULLER [HENRY WILLIAM), M. D., 

Physician to St. George's Hospital, London. 

ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their 

Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised 
English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. 



Dr. Fuller's work on diseases of the chest was so 
favorably received, that to many who did not know 
the extent of his engagements, it was a matter of won- 
der that it should be allowed to remain three years 
out of print. Determined, however, to improve it, 
Dr. Fuller would not consent to a mere reprint, and 



accordingly we have what might be with perfect jus- 
tice styled an entirely new work from his pen, the 
portion of the work treating of the heart and great 
vessels being excluded. Nevertheless, this volume is 
of almost equal size with the first. — London Medical 
Times and Gazette, July 20, 1867. 



w 
w 



'ILLIAMS [C. J. B.), M.D., 

Senior Consulting Physician to the Hospital for Consumption, Rrompton, and 

ILLIAMS [CHARLES T.), M.D., 

Physician to the Hospital for Consumption. 

PULMONARY CONSUMPTION; Its Nature, Varieties, and Treat- 

- ment. With an Analysis of One Thousand cases to exemplify its duration. In one neat 
octavo volume of about 350 pages, extra cloth. {Just Issued.) $2 50. 



He can still speak from a more enormous experi- 
ence, and a closer study of the morbid processes in- 
volved iu tuberculosis, than most living men. He 
owed it to himself, and to the importance of the sub- 
ject, to embody his views in a separate work, and 
we are glad »that he has accomplished this duty. 
After all, the grand teaching which Dr Williams has 
for the profession is to be found in his therapeutical 
chapters, and in the history of individual cases ex- 
tended, by dint of care, over ten, twenty, thirty, and 
even forty years. — London Lancet, Oct. 21, 1871. 

His results 'are more favorable than those of any 



previous author; but probably there is no malady, 
the treatment of which has been so much improved 
within the last twenty years as pulmonary consump- 
tion. To ourselves, Dr. Williams's chapters on Treat- 
ment are amongst the most valuable and attractive in 
the book, and would alone render it a standard work 
of reference. In conclusion, we would record our 
opinion that Dr. Williams's great reputation is fully 
maintained by this book. It is undoubtedly one <>f 
the most valuable works in the language upon any 
special disease. — Lond. Med. Times and Gaz., Nov. 
4, 1871. 



vol. 



extra 



LA ROCHE ON PNEUMONIA. 1 
cloth, of 500 pages. Price $3 00. 

BUCKLER ON FIBRO-BRONCHITIS AND RHEU- 
MATIC PNEUMONIA. 1 vol. 8vo. $1 25. 

FISKE FUND PRIZE ESSAYS ON CONSUMPTION. 
1 vol 8vo,, extra cloth, $1 00. 



SMITH ON CONSUMPTION; ITS EARLY ANDRE. 

MEDIABLE STAGES. 1 vol. Svo, pp. 254. $2 25. 
SALTER ON ASTHMA. 1 vol. 8vo. $2 50. 
WALSHE ON THE DISEASES OF THE HEART AND 

GREAT VESSELS. Third American edition. In 

1 vol. Svo., 420 pp ., cloth. $3 00. 



18 



Henry C. Lea's Publications — (Practice of Medicine). 



ROBERTS ( WILLIAM), M. D., 

-*- v Lecturer on Medicine in the Manchester School of Medicine, &c. 

A PRACTICAL TREATISE OjST URINARY AND RENAL 

EASES, including Urinary Deposits. Illustrated by numerous cases and engravings 
ond Edition, Revised. In one very handsome octavo volume. (Preparing.) 



DIS- 

. Sec- 



JJASHAM (W.R.), M.D., 

-*-* Senior Physician to the Westminster Hospital, &c. 

RENAL DISEASES: a Clinical Guide to their Diagnosis and Treat- 
ment. With illustrations. In one neat royal 12mo. volume of 304 pages. $2 00. {Just 
Issued. ) 



The chapters on diagnosis and treatment are very 
good, and the student and young practitioner will 
find them full of valuable practical hints. The third 
part, on the urine, is excellent, and we cordially 
recommend its perusal. The author has arranged 
his matter in a somewhat novel, and, we think, use- 
ful form. Here everything can he easily found, and, 
what is more important, easily read, for all the dry 
details of larger books hei-e acquire a new interest 
from the author's arrangement. This part of the 
book is full of good work. — Brit, and For. Medico- 
Chirurgical Review, July, 1870. 

The easy descriptions and compact modes of state- 



ment-render the book pleasing and convenient. — Am. 
Journ. Med. Sciences, July, 1870. 

A book that we believe will be found a valuable 
assistant to the practitioner and guide to the student. 
— Baltimore Med. Journal, July, 1S70. 

The treatise of Dr. Basham differs from the rest in 
its special adaptation to clinical study, and its con- 
densed and almost aphorismal style, which makes it 
easily read and easily understood. Besides, the 
author expresses some new views, which are well 
worthy of consideration. The volume is a valuable 
addition to this department of knowledge. — Pacific 
Med. and Surg. Journal, July, 1870. 



MORLAND ON RETENTION IN THE BLOOD OF THE ELEMENTS OF THE URINARY SECRETION. 
1 vol. 8vo., extra cloth. 75 cents. 



TONES (G. EANDFIELD), M. D., 

*J Physician to St. Mary's Hospital, &c. 

CLINICAL OBSERVATIONS 

DISORDERS. Second American Edition, 
extra cloth, $3 25. 
Taken as a whole, the work before us furnishes a 
short but reliable account of the pathology and treat- 
ment of a class of very common but certainly highly 
obscure disorders. The advanced student will find it 
a rich mine of valuable facts, while the medical prac- 
titioner will derive from it many a suggestive hint to 
aid him in the diagnosis of "nervous cases," and in 
determining the true indications for their ameliora- 
tion or cure.— Amer. Journ. Med. Sci., Jan. 1867. 



ON FUNCTIONAL NERVOUS 

In one handsome octavo volume of 348 pages, 



We must cordially recommend it to the profession 
of this country as supplying, in a great measure, a 
deficiency which exists in the medical literature of 
the English language. — New York Med. Journ., April, 
1867. 

The volume is a most admirable one — full of hints 
and practical suggestions. — Canada Med. Journal, 
April, 1867. 



ffjSSA YS ON NER VO US DISEASES (Now Ready.) 

ON DISEASES OF THE SPINAL COLUMN AND OF THE 

NERVES. By C. B. Radcliff, M. D., John Netten Radcliff, J. Warbtjrton Beg- 
bie, M. D., Francis E. Ainstie, M. D., and J. Russell Reynolds, M. D. 1 vol. 8vo., 
extra cloth, $1 50. 
This volume, which has been passing through the Library Department of the "Medical 
News" for 1870, consists of a series of essays from " Reynolds' System of Medicine" by gentle- 
men who have paid especial attention to the several affections of the nervous system. 



8 



M.D. 



LADE (D. D. 

DIPHTHERIA ; its Nature and Treatment, with an account of the His- 
tory of its Prevalence in various Countries. Second and revised edition. In one neat 
royal l2mo. volume, extra cloth. $1 25. 



TTUDSON (A.), M. D., M. R. 1. A., 

■*--*- Physician to the Meath Hospital. 

LECTURES ON THE STUDY OF FEVER. 

Cloth, $2 50. 



In one vol. 8v0., extra 



As an admirable summary of the present state of 
our knowledge concerning fever, the work will be as 
welcome to the medical man in active practice as to 
the student. To the hai-d-worked practitioner who 
wishes to refresh his notions concerning fever, the 

book will prove most valuable We heartily 

commend his excellent volume to students and the 
profession at large. — London Lancet, June 22, 1867 

The truly philosophical lectures of Dr. Hudson add 



much to our previous knowledge, all of which they, 
moreover, analyze and condense. This well-conceived 
task has been admirably executed in the lectures, il- 
lustrative cases and quotations being arranged in an 
appendix to each. We regret that space forbids our 
quotation from the lectures on treatment, which are, 
in regard to research and judgment, most masterly, 
and evidently the result of extended and mature ex- 
perience. — British Medical Journal, Feb. 22, 186S. 



T.YONS (ROBERT D.), K. C. G. 
A TREATISE ON FEYER; or, Selections from a Course of Lectures 

on Fever. Being part of a Course of Theory and Practice of Medicine. In one neat ootavo 
volume, of 362 pages, extra cloth. $2 25. 



Henry C. Lea's Publications — (Venereal Diseases, etc.). 



19 



TfUMSTEAD {FREEMAN J.), 31. D., 

-*-* Professor of Venereal Diseases at the Col. of Phys. and Surg., New York, Ac. 

THE PATHOLOGY AND TREATMENT OF VENEREAL BIS- 

EASES. Including the results of recent investigations upon the subject. Third edition, 

revised and enlarged, with illustrations. In one large and handsome octavo volume of 

over 700 pages, extra cloth, $5 00; leather, $6 00. {Just Issued.) 

In preparing this standard work again for the press, the author has subjected it to a very 

thorough revision. Many portions have been rewritten, and much new matter added, in order to 

bring it completely on a level with the most advanced condition of syphilography, but by careful 

compression of the text of previous editions, the work has been increased by only sixty-four pages. 

The labor thus bestowed upon it, it is hoped, will insure for it a continuance of its position as a 

complete and trustworthy guide for the practitioner. 



It is the most complete book with which we are ac- 
quainted in the language. The latest views of the 
best authorities are pat forward, and the information 
is well arranged— a great point for the student, and 
still more for the practitioner. The subjects of vis- 
ceral syphilis, syphilitic affections of the eyes, and 
the treatment of syphilis by repeated inoculations, are 
very fully discussed. — London Lancet, Jan. 7, IS71. 

Dr. Bumstead's work is already so universally 
known as the best treatise in the English language on 
venereal diseases, that it-may seem almost superflu- 
ous to say more of it than that a new edition has been 
issued. But the author's industry has rendered this 
new edition virtually a new work, and so merits as 



much special commendation as if its predecessors had 
not been published. As a thoroughly practical book 
on a class of diseases which form a large share of 
nearly every physician's practice, the volume before 
us is bv far the best of which we have knowledge. — 
N. Y. Medical Gazette, Jan. 28, 1S71. 

It is rare in the history of medicine to find any one 
book which contains all that a practitioner needs to 
know; while the possessor of "Bumstead on Vene- 
real" has no occasion to look outside of its covers for 
anything practical counected with the diagnosis, his- 
tory, or treatment of these affections. — N. Y. Medical 
Journal, March, 1871. 



ffULLERIER {A.), and ttUMSTEAD {FREEMAN J.), 

^ Surgeon to the Hopital du Midi. -*-* Professor of Venereal Diseases in the College of 

Physicians and Surgeons, N. Y. 

AN ATLAS OP VENEREAL DISEASES. Translated and Edited by 

Freeman J. Bumstead. In one large imperial 4to. volume of 328 pages, double-columns, 
with 26 plates, containing about 150 figures, beautifully colored, many of them the size of 
life; strongly bound in extra cloth, $17 00; also, in five parts, stout wrappers for mailing, at 
$3 per part. {Lately Published.) 
Anticipating a very large sale for this work, it is offered at the very low price of Three Dol- 
lars a Part, thus placing it within the reach of all who are interested in this department of prac- 
tice. Gentlemen desiring early impressions of the plates would do weU to order it without delay. 
A specimen of the plates and text sent free by mail, on receipt of 25 cents. 

The fifth and concluding number of this magnificent 
work has reached us, and we have no hesitation in 
saying that its illustrations surpass those of previous 
numbers.— Boston Med. and Surg. Journal, Jan. 14, 
1869. 

Other writers besides M. Cullerier have given us a 
good account of the diseases of which he treats, but 
no one has furnished us with such a complete series 
of illustrations of the venereal diseases. There is, 
however, an additional interest and value possessed 
by the volume before us ; for it is an American reprint 
and translation of M. Cullerier's work, with inci- 
dental remarks by one of the most eminent American 
syphilographers, Mr. Bumstead. The letter-press is 
chiefly M. Cullerier's, but every here and there a few 
lines or sentences are introduced by Mr. Bumstead ; 
and, as M. Cullerier is a unicist, while Mr. Bumstead 
is a dualist, this method of treating the subject adds 
very much to its interest. By this means a liveliness 
is imparted to the volume which many other treatises 
sorely lack. It is like reading the report of a conver- 
sation or debate ; for Mr. Bumstead often finds occa- 
sion to question M. Cullerier's statements or inferences, 
and this he does in a short and forcible way which 
helps to keep up the attention, and to make the book 
a very readable one. — Brit, and For. Medico-Chir. 
Review, July, 1869. 



We wish for once that our province was not restrict- 
ed to methods of treatment, that we might say some- 
thing of the exquisite colored plates in this volume. 
— London Practitioner, May, 1S69. 

As a whole, it teaches all that can be taught by 
means of plates and print. — London Lancet, March 
13, 1869. 

Superior to anything of the kind ever before issued 
an this continent. — Canada. Med. Journal, March, '69. 

The practitioner who desires to understand this 
branch of medicine thoroughly should obtain this, 
the most complete and best work ever published. — 
Dominion Med. Journal, May, 1869. 

This is a work of master hands on both sides. M. 
Cullerier is scarcely second to, we think we may truly 
6ay is a peer of the illustrious and venerable Ricord, 
while in this country we do not hesitate to say that 
Dr. Bumstead, as an authority, is without a rival 
Assuring our readers that these illustrations tell the 
whole history of venereal disease, from its inception 
to its end, we do not know a single medical work, 
which for its hind is more necessary for them to have. 
— California Med. Gazette, March, 1869. 

The most splendidly illustrated work in the lan- 
guage, and in our opinion far more useful than the 
French original.— Am. Journ. Med. Sciences, Jan. '69 



H 



In 



ILL [BERKELEY), 

Surgeon to the Lock Hospital, London. 

ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. 

extra cloth, $3 25. {Lately Published.) 

to whom we would most earnestly recommend its 
study ; while it is no less useful to the practitioner. — 
St. Louis Med. and Surg. Journal, May, 1S69. 

The most convenient and ready book of reference 
we have met with.— N. Y. Med. Record, May 1,1869. 



one handsome octavo volume 
Bringing, as it does, the entire literature of the dis- 
ease down to the present day, and giving with great 
ability the results of modern research, it is in every 
respect a most desirable work, and one which should 
find a place in the library of every surgeon. — Cali- 
fornia Med. Gazette, June, 1S69. 

Considering the scope of the book and the careful 
attention to the manifold aspects and details of its 
subject, it is wonderfully concise. All these qualities 
render it an especially valuable book to the beginner, 



_ Most admirably arranged for both student and prac- 
titioner, no other work on the subject equals it ; it is 
more simple, more easily studied. — Buffalo Med. and 
Surg. Journal, March, 1869. 



LALLEMAND AND WILSON ON THE CAUSES 
SYMPTOMS, AND TREATMENT OF SPERMA^ 



T0RRHO3A. 

cloth, $2 75. 



In one vol. 8vo., of about 400 pp. 



20 



Henry C. Lea's Publications — {Diseases of the Skin). 



TXTILSON (ERASMUS), F.R.S. 

ON DISEASES OF THE SKIN. With Illustrations on wood. Se^- 

enth American, from the sixth and enlarged English edition. In one large octavo volume 
of over 800 pages, $5. (Lately Published.) 

A SERIES OF PLATES ILLUSTRATING "WILSON ON DIS- 
EASES OF THE SKIN;" consisting of twenty beautifully executed plates, of which thir- 
teen are exquisitely colored, presenting the Normal Anatomy and Pathology of the Skin, 
and embracing accurate representations of about one hundred varieties of disease, most of 
them the size of nature. Price, in extra cloth, $5 50. 
Also, the Text and Plates, bound in one handsome volume. Extra cloth, $10. 
The industry and care with which the author has revised the present edition are shown by the 
fact that the volume has been enlarged by more than a hundred pages. In its present improved 
form it will therefore doubtless retain the position which it has acquired as a standard and classical 
authority, while at the same time it has additional claims on the attention of the profession as 
the latest and most complete work on the subject in the English language. 



Such a work as the one before us is a most capital 
aad acceptable help. Mr. Wilson has long been held 
as high authority in this department of medicine, and 
his book on diseases of the skin has long been re- 
garded as one of the best text-books extant on the 
subject. The present edition is carefully prepared, 
and brought up in its revision to the present time. In 
this edition we have also included the beautiful series 
of plates illustrative of the text, and in the last edi- 
tion published separately. There are twenty of these 
plates, nearly all of them colored to nature, and ex- 
hibiting with great fidelity the various groups of 
diseases treated of in the body of the work. — Cin- 
cinnati Lancet, June, 1863. 

No one treating skin diseases should be without 
a copy of this standard work. — Canada Lancet. 
August, 1863. 



We can safely recommend it to the profession aa 
the best work on the subject now in existence in 
the English language. — Medical Times and Gazette. 

Mr. Wilson's volume is an excellent digest of the 
actual amount of knowledge of cutaneous diseases ; 
it includes almost every fact or opinion of importance 
connected with the anatomy and pathology of the 
skin. — British and Foreign MedAcal Review. 

These plates are very accurate, and are executed 
with an elegance and taste which are highly creditable 
to the artistic skill of the American artist whoexecuted 
them.— St. Louis Med. Journal. 

The drawings are very perfect, and the finish and 
coloring artistic and correct; the volume is an indis- 
pensable companion to the book it illustrates and 
completes. — Charleston Medical Journal. 



JDY THE SAME AUTHOR. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE and Dis- 

eases op the skin. In one very handsome royal 12mo. volume. $3 50. (Lately Issued.) 



fiTELIGAN (J. MOORE), M.D., M.R.I. A. 

A PRACTICAL TREATISE ON DISEASES OF THE SKIN. 

Fifth American, from the second and enlarged Dublin edition by T. W. Belcher, M. D. 

In one neat royal 12mo. volume of 462 pages, extra cloth. $2 25. 

fully up to the times, and is thoroughly stocked with 
most valuable information. — New York Med. Record, 
Jan. 15, 1867. 

This instructive little volume appears once more- 
Since the death of its distinguished author, the study 
of skin diseases has been considerably advanced, and 
the results of these investigations have been added 
by the present editor to the original work of Dr. Neli- 
gan. This, however, has not so far increased its bulk 
as to destroy its reputation as the most convenient 
manual of diseases of the skin that can be procured 
by the student. — Chicago Med. Journal, Dec. 1866. 



Fully equal to all the requirements of students and 
young practitioners. It is a work that h,as stood its 
ground, that was worthy -the reputation of the au- 
thor, and the high position of which has been main- 
tained by its learned editor. —Dublin Med. Pi-ess and 
Circular, Nov. 17, 1869. 

Of the remainder of the work we have nothing be- 
yond unqualified commendation to offer. It is so far 
the most complete one of its size that has appeared, 
and for the student there can be none which can com- 
pare with it in practical value. All the late disco- 
veries in Dermatology have been duly noticed, and 
their value justly estimated ; in a word, the work is 
DF THE SAME AUTHOR. 



ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto 

volume, with exquisitely colored plates, &c, presenting about one hundred varieties of 
Extra cloth, $5 50. 

inclined to consider it a very superior work, com- 
bining accurate verbal description with sound views 
of the pathology and treatment of eruptive diseases. 
— Glasgow Med. Journal. 

A compend which will very much aid the practi- 
tioner in this difficult branch of diagnosis Taken 
with the beautiful plates of the Atlas, which are re- 
markable for their accuracy and beauty of coloring, 
it constitutes a very valuable addition to the library 
of a practical man. — Buffalo Med. Journal. 



The diagnosis of eruptive disease, however, under 
all circumstances, is very difficult. Nevertheless, 
Dr. Neligan has certainly, "as far as possible," given 
a faithful and accurate representation of this class of 
diseases, and there can be no doubt that these plates 
will be of great use to the student and practitioner in 
drawing a diagnosis as to the class, order, and species 
to which the particular case may belong. While 
looking over the "Atlas" we have been induced to 
examine also the "Practical Treatise," and we are 



TJILLIER [THOMAS), M.D., 

•*--*- Physician to the Skin Department of University College Hospital, &c. 

HAND-BOOK OF SKIN DISEASES, for Students and Practitioners 

Second American Edition. In one royal 12mo. volume of 358 pp. With Illustrations 
Extra cloth, $2 25. 

We can conscientiously recommend it to the stu- It is a concise, plain, practical treatise on the vari 

dent; the style is clear and pleasant to read, the ous diseases of the skin ; just such a work, indeed 

matter is good, and the descriptions of disease, w^th as was much needed, both by medical students and 

the modes' of treatment recommended, are frequently practitioners. — Chicago Medical Examiner, May 

illustrated with well-recorded cases. — London Med. lSt>5. 
Times and Gazette, April 1, 1S65. , 



Henry C. Lea's Publications — (Diseases of Children), 



21 



VHITH {J. LE WIS), M. D., 

*^ Professor of Morbid Anatomy in the Bellevue Hospital Med. College, N. Y. 

A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Second Edition, revised and greatly enlarged. In one handsome octavo 

volume. (Near'y Heady.) 

work is an illustration, and pervading every chapter 
of it is a spirit of sound judgment and common sense, 
"without which any work on any department of the 
practice of medicine is, to use the mildest word, de- 
fective. We are sorry that we cannot give further 
illustrations of the excellence of this book. — London 



An original and valuable work. — Glasgow Med. 
Journal, Feb. 1S71. 

The excellence of this book is one explanation of 
our not having reviewed it sooner. Taking it up from 
time to time, we have been freshly interested in its 
various chapters, and so been led to defer writing our 
opinion of it. It is one of those works with which 
we are happily becoming familiar, as coming to us 
from time to time from across the Atlantic, which 
contain all that is good in European works of the 
same kind, together with much that is original, both 
in reflection and observation. It is astonishing how 
well the American writers succeed in gleaning, and 
yet giving a fresh character to their books. This 



Lancet, Sept. 4, 1869. 

We have no work upon the Diseases of Infancy and 
Childhood which can compare with it. — Buffalo Med. 
and Surg. Journal, March, 1S69. 

The description of the pathology, symptoms, and 
treatment of the different diseases is excellent. — Am. 
Med. Journal, April, 1869. 



ffONDIE {D. FRANCIS), M.D. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. 

Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- 
printed pages, extra cloth, $5 25 ; leather, $6 25. {Lately Issued.) 

The present edition, which is the sixth, is fully up 
to the times in the discussion of all those points in the 
pathology and treatment of infantile diseases which 
have been brought forward by the German and French 
teachers. As a whole, however, the work is the best 
American one that we have, and in its special adapta- 
tion to American practitioners it certainly has no 
equal. — New York Med. Record, March 2, 1868. 

No other treatise on this subject is better adapted 
to the American physician. Dr. Condie has long stood 
before his countrymen as one peculiarly pre-eminent 



in this department of medicine. His work has been 
so long a standard for practitioners and medical stu- 
dents that we do no more now than refer to the fact 
that it has i-eached its sixth edition. We are glad 
once more to refresh the impressions of our earlier 
days by wandering through its pages, and at the same 
time to be able to recommend it to the youngest mem- 
bers of the profession, as well as to those who have 
the older editions on their shelves. — St. Louis Med. 
Reporter, Feb. 15, 1S6S. 



T\TEST {CHARLES), M.D., 

' ' Physician to the Hospital for Sick Children, &c. 

LECTURES ON THE DISEASES OF INFANCY AND CHILD- 

HOOD. Fourth American from the fifth revised and enlarged English edition. In one 



large and handsome octavo volume of 
leather, $5 50. 

Of all the English writers on the diseases of chil- 
dren, there is no one so entirely satisfactory to us as 
Dr. West. For years we have held his opinion as 
judicial, and have regarded him as one of the highest 



closely-printed pages. Extra cloth, $4 50 



living authorities in the difficult department of medi- 
cal science in which he is most widely known. — 
Boston Med. and Surg. Journal, April 26, 1S66. 



ffY THE SAME AUTHOR. (Just Ready) 

ON SOME DISORDERS OF THE NERYO ITS SYSTEM IN CHILD- 

HOOD; being the Lumleian Lectures delivered at the Royal College of Physicians of Lon- 
don, in March, 1871. In one volume, small 12mo., extra cloth, $1 00. 



&MITH [EUSTACE), 31. D., 

Physician to the Northwest London Free Dispensary for Sick Children. 

A PRACTICAL TREATISE ON THE WASTING DISEASES OF 

INFANCY AND CHILDHOOD. Second American, from the second revised and enlarged 
English edition. In one handsome octavo volume, extra cloth, $2 50. (Now Ready.) 



This is in every way an admirable book. The 
modest title which the author has chosen for it scarce- 
ly conveys an adequate idea of the many subjects 
upon which it treats. Wasting is so constant an at- 
tendant upon the maladies of childhood, that a trea- 
tise upon the wasting diseases of children must neces 
sarily embrace the consideration of many affections 
of which it is a symptom ; and this is excellently well 
done by Dr. Smith. The book might fairly be de- 



50. 

scribed as a practical handbook of the common dis- 
eases of children, so numerous are the affections con- 
sidered either collaterally or directly. We are 
acquainted with no safer guide to the treatment of 
children's diseases, and few works give the insight 
into the physiological and other peculiarities of chil- 
dren that Dr. Smith's book does. —Brit. Med. Journ., 
April S, 1S71. 



QUERSANT (P.), M. D., 

Honorary Surgeon to the Hospital for Sick Children, Paris. 

SURGICAL DISEASES OF INFANTS AND CHILDREN. Trans- 
lated by R. J. Dunglison, M. D. (Publishing in the Medical News and Library.) 
As this work embodies the experience of twenty years' service in the great Children's Hospital 
of Paris, it can hardly fail to maintain the reputation of the valuable practical series of volumes 
which have been laid before the subscribers of the " American Journal of the Medical Sci- 
ences." For terms, see p. 3. 

DEWEES ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN. Eleventh edition. 

8vo. of 548 pages. $2 80. 



1 vol. 



22 Henry C. Lea's Publications — (Diseases of Women). 

/THOMAS {T. GAILLARD),M.D., 

J- Professor of Obstetrics, &c in the College of Physicians and Surgeons, N. Y., &c. 

A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Third 

edition, enlarged and thoroughly revised In one large and handsome octavo volume of 
784 pages, with 246 illustrations. Cloth, $5 00; leather, $6 00. {Now Ready.) 
The author has taken advantage of the opportunity afforded by the call for another edition of 
this work to render it worthy a continuance of the very remarkable favor with which it has been 
received. Every portion has been subjected to a conscientious revision, several new chapters 
have been added, and no labor spared to make it a complete treatise on the most advanced con- 
dition of its important subject. The present edition therefore contains about one-third more 
matter than the previous one, notwithstanding which the price has been maintained at the former 
very moderate rate, rendering this one of the cheapest volumes accessible to the profession. 



If the excellence of a work is to be judged by its 
rapid sale, this one must take precedence of all others 
upon the same, or kindred subjects, as evidenced in 
the short time from its first appearance, in which a 
new edition is called for, resulting, as we are informed, 
from the exhaustion of the previous large edition. We 
deem it scarcely necessery to recommend this work 
to physicians as it is now widely known, and most 
of them already possess it, or will certainly do so. 
To students we unhesitatingly recommend it as the 
best text-book on diseases of females extant.— St. Louis 
Med. Reporter, June, 1869. 

Of all the army of books that have appeared of late 
years, on the diseases of the uterus and its appendages, 
we know of none that is so clear, compreheusive, and 
practical as this of Dr. Thomas', or one that we should 
more emphatically recommend to the young practi- 
tioner, as his guide.— California Med. Gazette, June, 
1869. 

If not the best work extant on the subject of which 
it treats, it is certainly second to none other. So 
short a time has elapsed since the medical press 
teemed with commendatory notices of the first edition, 
that it would be superfluous to give an extended re- 
view of what is now firmly established as the American 
text-book of Gynaecology. — N. Y. Med. Gazette, July 
17, 1869. 

This is a new and revised edition of a work which 
we recently noticed at some length, and earnestly 
commended to the favorable attention of our readers. 
The fact that, in the short space of one year, this 
6econd edition makes its appearance, shows that the 
general judgment of the profession has largely con- 
firmed the opinion we gave at that time. — Cincinnati 
Lancet, Aug. 1869. 

It is so short a time since we gave a full review of 
the first edition of this book, that we deem it only 
necessary now to call attention to the second appear- 
ance of the work. Its success has been remarkable, 
and we can only congratulate the author on the 
brilliant reception his book has received.— JV. Y. Med. 
Journal, April, 1869. 



We regard this treatise as the one best adapted to 
serve as a text-book on gynaecology. — St. Louis Med. 
and Surg. Journal, May 10, 1869. 

The whole work as it now stands is an absolute 
indispensable to any physician aspiring to treat the 
diseases of females with success, and according to the 
most fully accepted views of their aetiology and pa- 
thology.— Leavenworth Medical Herald, May, 1869. 

We have seldom read a medical book in which we 
found so much to praise, and so little — we can hardly 
say to object to — to mention with qualified commen- 
dation. We had proposed a somewhat extended 
review with copious extracts, but we hardly know 
where we should have space for it. We therefore 
content ourselves with expressing the belief that 
every practitioner of medicine would do well to pos- 
sess himself of the work. — Boston Med. and Surg. 
Journal, April 29, 1869. 

The number of works published on diseases of 
women is large, not a few of which are very valuable. 
But of those which are the most valuable we do not 
regard the work of Dr. Thomas as second to any. 
Without being prolix, it treats of the disorders to 
which it is devoted fully, perspicuously, and satisfac- 
torily. It will be found a treasury of knowledge to 
every physician who turns to its pages. We would 
like to make a number of quotations from the work 
of a practical bearing, but our space will not permit. 
The work should find a place in the libraries of all 
physicians. — Cincinnati Med. Repertory, May, 1S69. 

No one will be surprised to learn that the valuable, 
readable, and thoroughly practical book of Professor 
Thomas has so soon advanced to a second edition. 
Although very little time has necessarily been allowed 
our author for revision and improvement of the work, 
he has performed it exceedingly well. Aside from 
the numerous corrections which he has found neces- 
sary to make, he has added an admirable chapter on 
chlorosis, which of itself is worth the cost of the 
volume.— N. Y. Med. Record, May 15, 1869. 



fJHURCHILL {FLEETWOOD), M. D., 31. R. I. A. 



ESSAYS ON THE PUERPERAL EEYER, AND OTHER DIS- 
EASES PECULIAR TO WOMEN. Selected from the writings of British Authors previ- 
ous to the close of the Eighteenth Century. In one neat octavo volume of about 450 
pages, extra cloth. $2 50. 



ASHWELL {SAMUEL), M.D., 

-*-^- Late Obstetric Physician and Lecturer at Guy's Hospital. 

A PRACTICAL TREATISE ON THE DISEASES PECULIAR TO 

WOMEN. Illustrated by Cases derived from Hospital and Private Practice. Third Ame- 
rican, from the Third and revised London edition. In one octavo volume, extra cloth, of 
528 pages. $3 50. 



DEWEES'STREATTSE ON THE DISEASES OF FE- 
MALES. With illustrations. Eleventh Edition, 
with the Author's last improvements and correc- 



tions. In one octavo volume of 536 pages, with 
plates, extra cloth, $3 00. 



J2ARNES [ROBERT), M.D., F.R.O.P., 

-*-* Obstetric Physician to St. Thomas' 1 Hospital, &c. 

A PRACTICAL TREATISE ON THE DISEASES 

In one handsome octavo volume with illustrations. {Preparing.) 



OF WOMEN. 



Henry C. Lea's Publications — (Diseases of Women). 



23 



TTOBGE (HUGH L.). 31. D., 

■*--*- Emeritus Professor of Obstetrics, d-c, in the University of Pennsylvania. 

ON DISEASES PECULIAR TO WOMEN; including Displacements 

of the Uterus. "With original illustrations. Second edition, revised and enlarged. In 
one beautifully printed octavo volume of 531 pages, extra cloth. $4 50. (Lately Issued.) 
In the preparation of this edition the author has spared no pains to improve it with the results 
of his observation and study during the interval which has elapsed since the first appearance of 
the work. Considerable additions have thus been made to it, which have been partially accom- 
modated by an enlargement in the size of the page, to avoid increasing unduly the bulk of the 
volume. 



From Prof. W. H. Byford, of the Rush Medical 
College, Chicago. 

The book bears the impress of a master hand, and 
must, as its predecessor, prove acceptable to the pro- 
fession. In diseases of women Dr. Hodge has estab- 
lished a school of treatment that has become world- 
wide in fame. 

Professor Hodge's work is truly an original one 
from beginning to end, consequently no one can pe- 
ruse its pages without learning something new. The 
book, which is by no means a large one, is divided into 
two grand sections, so to speak : first, that treating of 
the nervous sympathies of the uterus, and, secondly, 
that which speaks of the mechanical treatment of dis- 
placements of that organ. He is disposed, as a non- 
believer in the frequency of inflammations of the 



uterus, to take strong ground against many of the 
highest authorities in this branch of medicine, and 
the arguments which he offers in support of his posi- 
tion are, to say the least, well put. Numerous wood- 
cuts adorn this portion of the work, and add incalcu- 
lably to the proper appreciation of the variously 
shaped instruments referred to by our author. As a 
contribution to the study of women's diseases, it is of 
great value, and is abundantly able to stand on its 
own merits. — N. ¥. Medical Record, Sept. 15, 1868. 

In this point of view, the treatise of Professor 
Hodge will be indispensable to every student in its 
department. The large, fair type and general perfec- 
tion of workmanship will render it doubly welcome. 
— Pacific Med. and Surg. Journal, Oct. 1*868. 



WjEST (CHARLES), 31.B. 

LECTURES ON THE DISEASES OF WOMEN. Third American, 

from the Third London edition. In one neat octavo volume of about 550 pages, extra 
cloth. $3 75 ; leather, $4 75. 

The reputation which this volume has acquired as a standard book of reference in its depart- 
ment, renders it only necessary to say that the present edition has received a careful revision at 
the hands of the author, resulting in a considerable increase of size. A few notices of previous 
editions are subjoined. 

The manner of the author is excellent, his descrip- i As a writer, Dr. "West stands, in our opinion, se- 
tions graphic and perspicuous, and his treatment up j cond only to Watson, the "Macaulay of Medicine;" 
to the level of the time— clear, precise, definite, and j he possesses that happy faculty of clothing instruc- 
marked by strong common sense. — Chicago Med. 
Journal, Dec. 1S61. 

We cannot too highly recommend this, the second 
edition of Dr. West's excellent lectures on the dis- 
eases of females. We know of no other book on this 
subject from which we have derived as much pleasure 
and instruction. Every page gives evidence of the 
honest, earnest, and diligent searcher after truth. He 
is not the mere compiler of other men's ideas, but his 
lectures are the result often years' patient investiga- 
tion in one of the widest fields for women's diseases — 
St. Bartholomew's Hospital. As a teacher, Dr. West 
is simple and earnest in his language, clear and com- 
prehensive in his perceptions, and logical in his de- 
ductions. — Cincinnati Lancet, Jan. 1S62. 

We return the author our grateful thanks for the 
vast amount of instruction he has afforded us. His 
valuable treatise needs no eulogy on our part. His 
graphic diction and truthful pictures of disease all 
epeak for themselves. — Medico-Chirurg. Review. 

Most justly esteemed a standard work It 

b«ars evidence of having been carefully revised, and 
is well worthy of the fame it has already obtained. 
— Dub. Med. Quar. Jour. 



h« _ 

tion in easy garments ; combining pleasure with 
profit, he leads his pupils, in spite of the ancient pro- 
verb, along a royal road to learning. His work is one 
which will not satisfy the extreme on either side, but 
it is one that will please the great majority who are 
seeking truth, and one that will convince the student 
that he has committed himself to a candid, safe, and 
valuable guide. — X. A. Med.-Chirurg Review. 

We must now conclude this hastily written sketch 
with the confident assurance to our readers that the 
work will well repay perusal. The conscientious, 
painstaking, practical physician is apparent on every 
page. — N. T. Journal of Medicine. 

We have to say of it, briefly and decidedly, that it 
is the best woi-k on the subject in any language, and 
that it stamps Dr. West as the facile princeps of 
British obstetric authors. — Edinburgh Med. Journal. 

We gladly recommend his lectures as in the highest 
degree instructive to all who are interested in ob- 
stetric practice. — London. Lancet. 

We know of no treatise of the kind so complete, 
and yet so compact. — Chicago Med. Journal. 



B 



Y THE SAME AUTHOR. 

AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OP 

ULCERATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 25. 



\TE1GS (CHARLES B.), 31. B.. 

J-"- Late Professor of Obstetrics, &c. in Jefferson Medical College, Philadelphia. 

WOMAN: HER DISEASES AND THEIR REMEDIES. A Series 

of Lectures to his Class. Fourth and Improved edition. In one large and beautifully 
printed octavo volume of over 700 pages, extra cloth, §5 00; leather, $6 00. 

Y THE SAME A UTHOR. 

ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED 

FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome 
octavo volume of 365 pages, extra cloth. §2 00. 



24 



Henry C. Lea's Publications — (Midwifery). 



JJODGE {HUGH L.), M.D., 

Emeritus Professor of Midwifery, &c. in the University of Pennsylvania, &c. 

THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Illus- 
trated with large lithographic plates containing one hundred and fifty-nine figures from 
original photographs, and with numerous wood-cuts. In one large and beautifully printed 
quarto volume of 550 double-columned pages, strongly bound in extra cloth, $14. 
The work of Dr. Hodge is something more than a 
simple presentation of his particular views in the de- 
partment of Obstetrics ; it is something more than an 



inary treatise on midwifery ; it is, in fact, a cyclo 
pasdia of midwifery. He has aimed to embody in a 
single volume the whole science and art of Obstetrics. 
An elaborate text is combined with accurate and va- 
ried pictorial illustrations, so that no fact or principle 
is left uustated or unexplained. — Am. Med. Times, 
Sept. 3, 1864. 

We should like to analyze the remainder of this 
excellent work, but already has this review extended 
beyond our limited space. We cannot conclude this 
notice without referring to the excellent finish of the 
work. In typography it is not to be excelled ; the 
paper is superior to what is usually afforded by our 
American cousins, quite equal to the best of English 
books. The engravings and lithographs are most 
beautifully executed. The work recommends itself 
for its originality, and is in every way a most valu- 
able addition to those on the subject of obstetrics. — 
Canada Med. Journal, Oct. 1864. 

It is very large, profusely and elegantly illustrated, 
and is fitted to take its place near the works of great 
obstetricians. Of the American works on the subject 
it is decidedly the best. — Edinb. Med. Jour., Dec. '64. 

■*■** Specimens of the plates and letter-press will be forwarded to any address, free by mail, 
on receipt of six cents in postage stamps. 



We have examined Professor Hodge's work with 
great satisfaction ; every topic is elaborated most 
fully. The views of the author are comprehensive, 
and concisely stated. The Tules of practice are judi- 
cious, and will enable the practitioner to meet every 
emergency of obstetric complication with confidence. 
— Chicago Med. Journal, Aug. 1864. 



More time than we have had at our disposal since 
we received the great work of Dr. Hodge is necessary 
to do it justice. It is undoubtedly by far the most 
original, complete, and carefully composed treatise 
on the principles and practice of Obstetrics which has 
ever been issued from the American press. — Pacific 
Med. and Surg. Journal, July, 1S64. 

We have read Dr. Hodge's book with great plea- 
sure, and have much satisfaction in expressing our 
commendation of it as a whole. It is certainly highly 
instructive, and in the main, we believe, correct. The 
great attention which the author has devoted to the 
mechanism of parturition, taken along with the con- 
clusions at which he has arrived, point, we think, 
conclusively to the fact that, in Britain at least, the 
doctrines of Naegele have been too blindly received. 
— Glasgow Med. Journal, Oct. 1864. 



qiANNER {THOMAS H.), M. D. 

ON THE SIGNS AND DISEASES OF PREGNANCY. First American 

from the Second and Enlarged English Edition. With four colored plates and illustrations 
on wood. In one handsome octavo volume of about 500 pages, extra cloth, $4 25. 
The very thorough revision the work has undergone 
has added greatly to its practical value, and increased 
materially its efficiency as a guide to the student and 
to the young practitioner. — Am. Journ. Med. Sci., 
April, 1868. 

With the immense variety of subjects treated of 
and the ground which they are made to cover, the im- 
possibility of giving an extended review of this truly 
remarkable work must be apparent. We have not a 
single fault to find with it, and most heartily com- 
mend it to the careful study of every physician who 
would not only always be sure of his diagnosis of 
pregnancy, but always ready to treat all the nume- 
rous ailments that are, unfortunately for the civilized 
women of to-day, so commonly associated with the 
function.— N. Y. Med. Record, March 16, 1868. 

We have much pleasure in calling the attention of 
our readers to the volume produced by Dr. Tanner, 
the second edition of a work that was, in its original 



state even, acceptable to the profession. We recom- 
mend obstetrical students, young and old, to have 
this volume in their collections. It contains not only 
a fair statement of the signs, symptoms, and diseases 
of pregnancy, but comprises in addition much inter- 
esting relative matter that is not to be found in any 
other work that we can name. — Edinburgh Med. 
Journal, Jan. 1868. 

In its treatment of the signs and diseases of preg- 
nancy it is the most complete book we know of, 
abounding on every page with matter valuable to the 
general practitioner. — Cincinnati Med. Repertory, 
March, 1S6S. 

This is a most excellent work, and should be on the 
table or in the library of every practitioner. — Hicm- 
boldt Med. Archives, Feb. 186S. 

A valuable compendium, enriched by his own la- 
bors, of all that is known on the sigus and diseases of 
pregnancy.— St. Louis Med. Reporter, Feb. 15, 1868 



s 



WAYNE {JOSEPH GRIFFITHS), M. D., 

Physician-Accoucheur to the British General Hospital, &c. 

OBSTETRIC APHORISMS FOR THE USE OF STUDENTS COM- 
MENCING MIDWIFERY PRACTICE. From the Fourth and Revised London Edition, 
with Additions by E. R. Hutchins, M. D. With Illustrations. In one neat 12mo. vol- 
ume. Extra cloth, $1 25. (Lately Published.) 



It is really a capital little compendium of the sub- 
ject, and we recommend young practitioners to buy it 
and carry it with them when called to attend cases of 
labor. They can while away the otherwise tedious 
hours of waiting, and thoroughly fix in their memo- 
ries the most important practical suggestions it con- 
tains. The American editor has materially added by 
his notes and the concluding chapters to the com- 
pleteness and general value of the book. — Chicago 
Med. Journal, Feb. 1870. 

The manual before us contains in exceedingly small 
compass — small enough to carry in the pocket. — about 
all there is of obstetrics, condensed into a ni\tshell of 
Aphorisms. The illustrations are well selected, and 
serve as excellent reminders of the conduct of labor — 
regular aud difficult. — Cincinnati Lancet, April, '70. 

This is a mostadmirable little work, and completely 



answers the purpose. It is not only valuable for 
young beginners, but no one who is not a proficient 
in the art of obstetrics should be without it, because 
it condenses all that is necessary to know for ordi- 
nary midwifery practice. We commend the book 
most favorably. — St. Louis Med. and Surg. Journal, 
Sept. 10, 1870. 

A studied perusal of this little book has satisfied 
us of its eminently practical value. The object of the 
work, the author says, in his preface, is to give the 
student a few brief and practical directions respect- 
ing the management of ordinary cases of labor ; and 
also to poiut out to him in extraordinary cases whea 
and how he may act upon his own responsibility, and 
wheu he ought to send for assistance. — N. Y. Medical 
Journal, May, 1870. 



Henry C. Lea's Publications — (Midwifery), 



25 



MEIGS {CHARLES D.), 31. D., 

•+■*-*- Lately Professor of Obstetrics, &c, in the 

OBSTETRICS: THE SCIENCE 

revised. With one hundred and thirty i 
volume of 760 large pages. Extra cloth, I 

It is to the student that our author has more par- 
ticularly addressed himself; but to the practitioner 
we believe it would be equally serviceable as a book 
of reference. No work that we have met with so 
thoroughly details everything that falls to the lot of 
the accoucheur to perform. Every detail, no matter 
how minute or how trivial, has found a place.— 
Canada Medical Journal, July, 1867. 

The original edition is already so extensively and 



Jefferson Medical College, Philadelphia. 

AND THE ART. Fifth edition, 

llustrations. In one beautifully printed octavo 

55 50; leather, $6 50. 

favorably known to the profession that no recom- 
mendation is necessary ; it is sufficient to say, the 
present edition is very much extended, improved, 
and perfected. Whilst the great practical talents and 
unlimited experience of the author render it a most 
valuable acquisition to the practitioner, it is so con- 
densed as to constitute a most eligible and excellent 
text-book for the student.— Southern Med. and Surg, 
journal, July, 1867. 



JOAMSBOTHAM [FRANCIS H.), 31. D. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDI- 

CI]NE AND SURGERY, in reference to the Process of Parturition. A new and enlarged 
edition, thoroughly revised by the author. With additions by W. V. Keating, M. D., 
Professor of Obstetrics, &c, in the Jefferson Medical College, Philadelphia. In one large 
and handsome imperial octavo volume of 650 pages, strongly bound in leather, with raised 
bands; with sixty-four beautiful plates, and numerous wood-cuts in the text, containing in 
all nearly 200 large and beautiful figures. $7 00. 



We will only add that the student will learn from 
It all he need to know, and the practitioner will find 
it, as a book of reference, surpassed by none other. — 
Stethoscope. 

The character and merits of Dr. Eamsbotham's 
work are so well known and thoroughly established, 
that comment is unnecessary and praise superfluous. 
The illustrations, which are numerous and accurate, ' 
are executed in the highest style of art. We cannot j 
too highly recommend the work to our readers. — St. 
Louis Med. and Surg. Journal. 



To the physician's library it is indispensable, while 
to the student, as a text-book, from which to extract 
the material for laying the foundation of an education 
on obstetrical science, it has no superior. — Ohio Med,, 
and Surg. Journal. * 

When we call to mind the toil we underwent in 
acquiring a knowledge of this subject, we cannot but 
envy the student of the present day the aid which 
this work will afford him. — Am. Jour, of the Med. 
Sciences. 



fJHURCHILL [FLEETWOOD), M.D., 31. R.I. A. 

ON THE THEORY AND PRACTICE OF MIDWIFERY. A new 

American from the fourth revised and enlarged London edition. With notes and additions 
by D. Francis Coxdie, M. D., author of a "Practical Treatise on the Diseases of Chil- 
dren,' 1 &c. With one hundred and ninety-four illustrations. In one very handsome octavo 
volume of nearly 700 large pages. Extra cloth, $4 00 ; leather, $5 00. 
In adapting this standard favorite to the wants of the profession in the United States, the editor 
has endeavored to insert everything that his experience has shown him would be desirable for the 
American student, including a large number of illustrations. With the sanction of the author, 
he has added, in the form of an appendix, some chapters from a little "Manual for Midwives and 
Nurses," recently issued by Dr. Churchill, believing that the details there presented can hardly 
fail to prove of advantage to the junior practitioner. The result of all these additions is that the 
work now contains fully one-half more matter than the last American edition, with nearly one- 
half more illustrations; so that, notwithstanding the use of a smaller type, the volume contains 
almost two hundred pages more than before. 



These additions render the work still more com- 
plete and acceptable than ever; and with the excel- 
lent style in which the publishers have presented 
this edition of Churchill, we can commend it to the 
profession with great cordiality and pleasure. — Cin- 
cinnati Lancet. 

Few work? on this branch of medical science are 
equal to it, certainly none excel it, whether in regard 
to theory or practice, and in one respect it is superior 
to all others, viz., in its statistical information, and 
therefore, on these grounds a most valuable work for 
the physician, student, or lecturer, all of whom will 
find in it the information which they are seeking. — 
Brit. Am. Journal. 

The present treatise is very much enlarged and 
amplified beyond the previous editions but nothing 



has been added which could be well dispensed with. 
An examination of the table of contents shows how 
thoroughly the author has gone over the ground, and 
the care he has taken in the text to present the sub- 
j ects in all their bearings, will render this new edition 
even more necessary to the obstetric student than 
were either of the former editions at the date of their 
appearance. No treatise on obstetrics with which we 
are acquainted can compare favorably with this, in 
respect to the amount of material which has been 
gathered from every source. — Boston Med. and Surg. 
Journal. 

There is no better text-book for students, or work 
of reference and study for the practising physician 
than this. It should adorn and enrich every medica3 
library. — Chicago Med. Journal. 



M' 



ONTGOMERY (W. F.), M.I)., 

Professor of Midwifery in the King's and Queen's College of Physicians in Ireland. 

AN EXPOSITION OF THE SIGNS AND SYMPTOMS OF PREG- 
NANCY. With some other Papers on Subjects connected with Midwifery. From the second 
and enlarged English edition. With two exquisite colored plates, and numerous wood-cuts. 
In one very handsome octavo volume of nearly 600 pages, extra cloth. $3 75. 



RIGBY'S SYSTEM OF MIDWIFERY. With Notes 
and Additional Illustrations. Second American 
edition. One volume octavo, extra cloth, 422 pages. 
$2 50. 



DEWEES'S COMPREHENSIVE SYSTEM OF MID- 
WIFERY. Twelfth edition, with the author's last 
improvements and corrections. In one octavo vol- 
ume, extra cloth, of 600 pages. $3 50. 



26 



Henry C. Lea's Publications — (Surgery). 



Q.ROSS {SAMUEL D.), M.D., 

*f Professor of Surgery in the Jefferson Medical College of Philadelphia. 

A SYSTEM OF SURGERY: Pathological, Diagnostic, Therapeutic, 

and Operative. Illustrated by upwards of Thirteen Hundred Engravings. Fourth edition, 
carefully revised, and improved. In two large and beautifully printed royal octavo volumes 
of 2200 pages, strongly bound in leather, with raised bands. $15 00. 
The continued favor, shown by the exhaustion of successive large editions of this great work, 
s proves that it has successfully supplied a want felt by American practitioners and students. Though 
but little over six years have elapsed since its first publication, it has already reached its fourth 
edition, while the care of the author in its revision and correction has kept it in a constantly im- 
proved shape. By the use of a close, though very legible type, an unusually large amount of 
matter is condensed in its pages, the two volumes containing as much as four or five ordinary 
octavos. This, combined with the most careful mechanical execution, and its very durable binding, 
renders it one of the cheapest works accessible to the profession. Every subject properly belonging 
to the domain of surgery is treated in detail, so that the student who possesses this work may be 
said to have in it a surgical library. 



It must long remain the most comprehensive work 
on this important part of medicine. — Boston Medical 
and Surgical Journal, March 23, 1865. 

We have compared it with most of our standard 
works, such as those of Erichsen, Miller, Fergusson, 
Syme, and others, and we must, in justice to our 
author, award it the pre-eminence. As a work, com- 
plete in almost every detail, no matter how minute 
or trifling, and embracing every subject known in 
the principles and practice of surgery, we believe it 
stands without a rival. Dr. Gross, in his preface, re- 
marks "my aim has been to embrace the whole do- 
main of surgery, and to allot to every subject its 
legitimate claim to notice;" and, we assure our 
readers, he has kept his word. It is a work which 
we can most confidently recommend to our brethren, 
for its utility is becoming the more evident the longer 
it is upon the shelves of our library. — Canada Med. 
Journal, September, 1865. 

The first two editions of Professor Gross' System of 
Surgery are so well known to the profession, and so 
highly prized, that it would be idle for us to speak in 
praise of this work. — Chicago Medical Journal, 
September, 1865. 

We gladly indorse the favorable recommendation 
of the work, both as regards matter and style, which 
we made when noticing its first appearance. — British 
and Foreign Medico- Chirurgical Review, Oct. 1865. 

The most complete work that has yet issued from 
the press on the science and practice of surgery. — 
London Lancet. 

This system of surgery is, we predict, destined to 
take a commanding position in our surgical litera- 
ture, and be the crowning glory of the author's well 
earned fame. As an authority on general surgical 
subjects, this work is long to occupy a pre-eminent 
place, not only at home, but abroad. We have no 



hesitation in pronouncing it without a rival in our 
language, and equal to the best systems of surgery in 
any language.— A 7 : Y. Med. Journal. 

Not only by far the best text-book on the subject, 
as a whole, within the reach of American students, 
but one which will be much more than ever likely 
to be resorted to and regarded as a high authority 
abroad. — Am. Journal Med. Sciences, Jan. 1865. 

The work contains everything, minor and major, 
operative and diagnostic, including mensuration and 
examination, venereal diseases, and uterine manipu- 
lations and operations. It is a complete Thesaurus 
of modern surgery, where the student and practi- 
tioner shall not seek in vain for what they desire. — 
San Francisco Med. Press, Jan. 1865. 

Open it where we may, we find sound practical in- 
formation conveyed in plain language. This book is 
no mere provincial or even national system of sur- 
gery, but a work which, while very largely indebted 
to the past, has a strong claim on the gratitude of the 
future of surgical science.— Edinburgh Med. Journal, 
Jan. 1865. 

A glance at the work is sufficient to show that the 
author and publisher have spared no labor in making 
it the most complete "System of Surgery" ever pub- 
lished in any country. — St. Louis Med. and Surg 
Journal, April, 1865. 

A system of surgery which we think unrivalled in 
our language, and which will indelibly associate his 
name with surgical science. And what, in our opin- 
ion, enhances the value of the work is that, while the 
practising surgeon will find all that he requires in it, 
it is at the same time one of the most valuable trea- 
tises which can be put into the hands of the student 
seeking to know the principles and practice of this 
branch of the profession which he designs subse- 
quently to follow.— The Brit. Am. Journ., Montreal. 



BY THE SAME AUTHOR. 

A PRACTICAL TREATISE ON FOREIGN BODIES IN 

AIR-PASSAGES. In 1 vol. 8vo. cloth, with illustrations, pp. 468. $2 75. 



THE 



SKEY'S OPERATIVE SURGERY. In 1 vol. 8vo. 

cloth, of over 650 pages ; with about 100 wood-cuts. 

$3 25 
COOPER'S LECTURES ON THE PRINCIPLES AND 

Pkactice of Surgery. In 1 vol. 8vo. cloth, 750 p. $2. 



GIBSUW'S INSTITUTES AND PRACTICE OF SUR- 
uery. Eigiith edition, improved and altered. With 
thirty-four plates. In two handsome octavo vol- 
umes, about 1000 pp., leather, raised bands. $6 50. 



liflLLER {JAMES), 

•*■"-*- Late Professor of Surgery in the University of Edinburgh, &c. 

PRINCIPLES OF SURGERY. Fourth American, from the third and 

revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with 
two hundred and forty illustrations on wood, extra cloth. $3 75. 
DF THE SAME AUTHOR. 

THE PRACTICE OF SURGERY. Fourth American, from the last 

Edinburgh edition. Revised by the American editor. Illustrated by three hundred and 
sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra 
cloth. $3 75. 

^ARGENT {F. W:) } M.D. 

ON BANDAGING AND OTHER OPERATIONS OF MINOR SUR- 

GERY. New edition, with an additional chapter on Military Surgery. One handsome royal 
12mo. volume, of nearly 400 pages, with 184 wood-cuts Extra cloth, $1 75. 



Henry C. Lea's Publications — (Surgery). 



27 



J^SHHURST [JOHN, Jr.), M.D., 

Surgeon to the Episcopal Hsopital, Philadelphia. 

THE PRINCIPLES AND PRACTICE OF SURGERY. In one 

very large and handsome octavo volume of about 1000 pages, with nearly 550 illustrations, 
extra cloth, $6 50; leather, raised bands, $7 50. (Just Ready.) 

The object of the author has been to present, within as condensed a compass as possible, a 
complete trentise on Surgery in all its branches, suitable both as a text-book for the student and 
a work of reference for the practitioner. So much has of late years been done for the advance- 
ment of Surgical Art and Science, that there seemed to be a want of a work which should present 
the latest aspects of every subject, and which, by its American character, should render accessible 
to the profession at large the experience of the practitioners of both hemispheres. This has been 
the aim of the author, and it is hoped that the volume will be found to fulfil its purpose satisfac- 
torily. The plan and general outline of the work will be seen by the annexed 
CONDENSED SUMMAEY OF CONTENTS. 

Chapter I. Inflammation. II. Treatment of Inflammation. III. Operations in general : 
Anaesthetics. IV. Minor Surgery. V. Amputations. VI. Special Amputations. VII. Effects 
of Injuries in General : Wounds. VIII. Gunshot Wounds. IX. Injuries of Bloodvessels. X. 
Injuries of Nerves, Muscles and Tendons, Lymphatics, Bursa, Bones, and Joints. XI. Fractures. 
XII. Special Fractures. XIII. Dislocations. XIV. Effects of Heat and Cold. XV. Injuries 
of the Head. XVI. Injuries of the Back. XVII. Injuries of the Face and Neck. XVIII. 
Injuries of the Chest. XIX. Injuries of the Abdomen and Pelvis. XX. Diseases resulting from 
Inflammation. XXL Erysipelas. XXII. Pyasinia. XXIII. Diathetic Diseases : Struma (in- 
cluding Tubercle and Scrofula); Rickets. XXIV. Venereal Diseases ; Gonorrhoea and Chancroid. 
XXV. Venereal Diseases continued : Syphilis. XXVI. Tumors. XXVII. Surgical Diseases of 
Skin, Areolar Tissue, Lymphatics, Muscles, Tendons, and Bursae. XXVIII. Surgical Disease 
of Nervous System (including Tetanus). XXIX. Surgical Diseases of Vascular System (includ- 
ing Aneurism). XXX. Diseases of Bone. XXXI. Diseases of Joints. XXXII. Excisions. 
XXXIII. Orthopaedic Surgery. XXXIV. Diseases of Head and Spine. XXXV. Diseases of the 
Eye. XXXVI. Diseases of the Ear. XXXVII. Diseases of the Face and Neck. XXXVIII. 
Diseases of the Mouth, Jaws, and Throat. XXXIX. Diseases of the Breast. XL. Hernia. 
XLI. Special Herniae. XLII. Diseases of Intestinal Canal. XLIII. Diseases of Abdominal 
Organs, and various operations on the Abdomen. XLIV. Urinary Calculus. LXV. Diseases of 
Bladder and Prostate. XLVI. Diseases of Urethra. XLVII. Diseases of Generative Organs. 
Index. 



Its author has evidently tested the writings and 
experiences of the past and present in the crucible 
of a careful, analytic, and honorable mind, and faith- 
fully endeavored to bring his work up to the level of 
the highf.st standard of practical surgery He is 
frank and defiuit«, and gives us opinions, and gene- 
rally sound ones, instead of a mere resume of the 
opinions of others. He is conservative, but not hide- 
bound by authority. His style is clear, elegant, and 
scholarly. The w< rk is an admirable text book, and 
a useful book of reference It is a credit to American 
professional literature, and one of the first ripe fruits 
of the soil fertilized by the blood of our late unhappy 
war.— N. Y. Med. Record, Feb. 1, 1S72. 



Indeed, the work as a whole must be regarded as 
an excellent and concise exponent of modern sur- 
gery, and as such it will be found a valuable text- 
book for the student, and a useful book of reference 
for the general practitioner. — iV. Y. Med. Journal, 
Feb. 1872. 

It gives us great pleasure to call the attention of the 
profession to this excellent work. Our knowledge of 
its talented and accomplished author led ns to expect 
from him a very valuable treatise upon subjects to 
which he has repeatedly given evidence of having pro- 
fitably devoted much time and labor, and we are in no 
way disappointed.— Pkila. Med. Times, Yah. 1, 1872. 



fRIGHSEN {JOHN), * 

■U Senior Surgeon to University College Hospital. 

THE SCIENCE AND ART OF SURGERY; being a Treatise on Sur- 

gical Injuries, Diseases, and Operations. From the Fifth enlarged and carefully revised 
London Edition. With Additions by John Ashhurst. Jr., M. D., Surgeon to the Episcopal 
Hospital, &o. Illustrated by over six hundred Engravings on wood. In one very large 
and beautifully printed imperial octavo volume, containing over twelve hundred closely 
printed pages : cloth, $7 50 ; leather, raised bands, $8 50. (Lately Published.) 
Erichsen's Surgery needs no review at the present last London edition of •■ Erichsen's Surgery". the 

practitioner and student are supplied with a guide 
and text-book which apparently leaves nothing to be 
desired. Full and complete in every essential par- 
ticular, and inculcating the most advanced and cor- 
rect modes of practice, it is certain to come into very 
general use. The additions of Dr. Ashhurst, thongn 
not extensive, are to the point; they relate chieiiy 
to items of American practice. — The Journal of Psy- 
chological Medicine, Jan. 1S70. 



day. Long ago it took and has since maintained 
leading position in surgical literature, and this posi- 
tion is so firmly held, that no efforts on the part of a 
reviewer would serve to weaken the estimate which 
has been placed upon the book — nor, indeed, could 
they materially strengthen it. The duty, then, de- 
volving upon us is simply to note the appearance of 
this new edition, and to point out the improvements 
therein made. — N. Y. Med. Journal, Jan. 1870. 
In the recent republication in this country of the 



JjY THE SAME AUTHOR. (Just Issued.) 

ON RAILWAY, AND OTHER INJURIES OF THE NERVOUS 

SYSTEM. In small octavo volume. Extra cloth, $1 00. 



piRRIE ( WILLIAM), F. R. S. E., 

-*- Professor of Surgery in the University of Aberdeen. 

THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by 

John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the 
Pennsylvania Hospital, &g. In one very handsome octavo volume of 780 pages, with 316 
illustrations, extra cloth. $3 75. 



28 



Henry C. Lea's Publications — (Surgery). 



T)RUITT {ROBERT), M.R. C.S., Sfc. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

A new and revised American, from the eighth enlarged and improved London edition. Iilufi- 
trated with four hundred and thirty -two wood-engravings. In one very handsome octa-vo 
volume, of nearly 700 large and closely printed pages. Extra cloth, $4 00; leather, $5 00. 



All that the surgical student or practitioner could 
desire. — Dublin Quarterly Journal. 

It is a most admirable book. We do not know 
when we have examined one with more pleasure.- — 
Boston Med. and StirQ, Journal. 

In Mr. Druitt's book, though containing only some 
seven hundred pages, both the principles and the 
practice of surgery are treated, and so clearly and 
perspicuously, as to elucidate every important topic. 
The fact that'fwelve editions have already been called 
for, in these days of active competition, would of 
itself show it to possess marked superiority. We 
have examined the book most thoroughly, and can 
say that this success is well merited. ■ His book, 
moreover, possesses the inestimable advantages of 
having the subjects perfectly well arranged and clas- 
sified, and of being written in a style at once clear 
and succinct. — Am. Journal of Med. Sciences. 

Whether we view Druitt's Surgery as a guide to 
operative procedures, or as representing the latest I Journal. 



theoretical surgical opinions, no work that we are at 
present acquainted with can at all compare with it. 
It is a compendium of surgical theory (if we may use 
the word)' and practice in itself, and well deservos 
the estimate placed upon it. — Brit. Am. Journal. 

Thus enlarged and improved, it will continue to 
rank among our best text-books on elementary sur- 
gery. — Columbus Rev. of Med. and Surg. 

We must close this brief notice of an admirable 
work by recommending it to the earnest attention of 
every medical student. — Charleston Medical Journal 
and Review. 

A text-book which the general voice of the profes- 
sion in both England and America has commended as 
one of the most admirable "manuals," or, "vade 
mecum,' 1 '' as its English title runs, which can be 
placed in the hands of the student. The merits of 
Druitt's Surgery are too well known to every one to 
need any further eulogium from us. — Nashville Med. 



TJAMILTON [FRANK K), M.D., 

Professor of Fractures and Dislocations, &c, in Bellevue Hosp. Med. College, New York. 

A PRACTICAL TREATISE ON FRACTURES AND DISLOCA- 

TIONS. Fourth edition, thoroughly revised. In one large and handsome octavo volume 
oi nearly 800 pages, with several hundred illustrations. Extra cloth, $5 75 ; leather, $6 75. 
{Just Issited.) 
In revising this standard work, the author has omitted much which the progress of science has 
seemed to render less important, and has thus gained room for a large amount -of new matter, 
so that with but little increase in the size of the volume he has yet been able to present the sub- 
ject in its most recent aspect. The series of illustrations has likewise undergone a thorough 
revision ; nearly one-fourth of the wood-cuts in the last edition have been rejected, and their places 
supplied, for the most part, with original drawings, representing the most approved forms of ap- 
parel, and the latest views with regard to the pathology of fractures and dislocations. In its 
present improved form, therefore, it is hoped that the volume may maintain the character which 
it has acquired of a standard authority on every detail of its important subject. 

rable treatise, which we have always considered the 
mo?t complete and reliable work on the subject. As 
a whole, the work is without an equal in the litera- 
ture of the profession. — Boston Med. and Surg. 
Journ., Oct. 12, 1871. 



It is not, ot course, our intention to review in ex- 
tenso, Hamilton on "Fractures and Dislocations." 
Eleven years ago such review might not have been 
out of place ; to-day the work is an authority, so well, 
so generally, and so favorably known, that it only 
remains for the reviewer to say that a new edition is 
just out, and it is better than either of its predeces- 
sors. — Cincinnati Clinic, Oct. 14, 1S71. 

Undoubtedly the best work on Fractures and Dis- 
locations in#he English language. — Cincinnati Med. 
Repertory, Oct. 1S71. 

We have once more before us Dr. Hamilton's admi- 



It is unnecessary at this time to commeudthe book, 
except to such as are beginners in the study of this 
particular branch of surgery. Every practical sur- 
geon in this country and abroad knows of it as a most 
trustworthy guide, and one which they, in common 
with us, would unqualifiedly recommend as the high- 
est authority in any language.— N. Y. Med. Record, 
Oct 16, 1871. 



ASHTON [T. J.). 
ON THE DISEASES, INJURIES, AND MALFORMATIONS OF 

THE RECTUM AND ANUS; with remarks on Habitual Constipation. Second American, 
from the fourth and enlarged London edition. With handsome illustrations. In one very 
beautifully printed octavo volume of about 300 pages. $3 25. 

The short period which has elapsed since the ap- 
pearance of the former American reprint, and the 
numerous editions published in England, are the best 
arguments we can offer of the merits, and of the usd- 
lessness of any commendation on our part of a book 
already so favorably known to our readers. — Boston 
Med. and Surg. Journal, Jan. 25, 1866. 



We can recommend this volume of Mr. Ashton's in 
the strongest terms, as containing all the latest details 
of the pathology and treatment of diseases connected 
with the rectum. — Canada Med. Journ., March, 1866. 

One of the most valuable special treatises that the 
physician and surgeon can have in his library. — 
Chicago Medical Examiner, Jan. 1866. 



JD1GELO W [HENRY J.), M. D., 

•*-* Professor of Surgery in the Massachusetts Med. College. 

ON THE MECHANISM OF DISLOCATION AND FRACTURE 

OF THE HIP. With the Eeduction of the Dislocation by the Flexion Method. With 
numerous original illustrations. In one very handsome octavo volume. Cloth. $2 50. 
{Lately Issued.) 
We cannot too highly praise this book as the work graph is largely illustrated with exquisitely executed 
of an accomplished and scientific surgeon. We do woodcuts, after photographs, which help to elucidate 
not hesitate to say that he has done much to clear up the admirable subject-matter of the text. We cor- 
the obscurities connected with the mechanism of dis- dially commend the " Hip," by Dr. Bigelow, to the 
location of the hip-joint, and he has laid down most attention of surgeons.— Dublin' Quarterly Journal of 
valuable practical rules for the easy and most sue- Medical Science, Feb. 1870. 
cessful management of these injuries The mono- 



Henry C. Lea's Publications — (Surgery). 29 

T/^ELLS {J. SOELBERG), 

f V Professor of Ophthalmology in King's College Hospital, &c. 

A TREATISE ON DISEASES OF THE EYE. First American 

Edition, with additions ; illustrated with 216 engravings on wood, and six colored plates. 

Together with selections from the Test-types of Jaeger and Snellen. In one large and 

very handsome octavo volume of about 750 pages: extra cloth, $5 00; leather, $8 00. 

{Lately Issued.) 
A work has long been wanting which should repre-sent adequately and completely the present 
aspect of British Ophthalmology, and this want it has been the aim of Mr. Wells to supply. The 
favorable reception of his volume by the medical press is a guarantee that he has succeeded in 
his undertaking, and in reproducing the work in this country every effort has been made to 
render it in every way suited to the wants of the American practitioner. Such additions as 
seemed desirable have been introduced by the editor, Dr. I. Minis Hays, and the number of 
illustrations has been more than doubled. The importance of test-types as an aid to diagnosis 
is so universally acknowledged at the present day that it seemed essential to the completeness of 
the work that they should be added, and as the author recommends the use of those both of Jaeger 
and of Snellen for different purposes, selections have been made from each, so that the practitioner 
may have at command all the assistance necessary. The work is thus presented as in every way 
fitted to merit the confidence of the American profession. 

In this respect the work before us is of much more I mend it to all who desire to consult a really good 
service to the general practitioner than those heavy work on ophthalmic science. The American edition 
compilations which, in giving every person's views, | of Mr. "Wells' treatise was superintended in its passage 
too often neglect to specify those which are most in i through the press by Dr. I. Minis Hays, who has 
accordance with the author's opinions, or in general J added some notes of his own where it seemed desira- 
acceptance. We have no hesitation in recommending ble. He has also introduced more than one hundred 
this treatise, as, on the whole, of all English works ; new additional wood-cuts, and added selections from 
on the subject, the one best adapted to the wants of i the test-types of Jaeger and of Snellen. — Leavenworth 
the general practitioner.— Edinburgh Med. Journal, 
March, 1870. 

A treatise of rare merit. It is practical, compre- 



Med. Herald, Jan. 1870. 

Without doubt, one of the best works upon the sub- 



ject which has ever been published ; it is complete on 
the subject of which it treats, and is a necessary work 
found difficult to the student, he has dwelt at length j for every physician who attempts to treat diseases of 
nd entered into full explanation. After a careful i the eye. — Dominion Med. Journal, Sept. 1869. 



hensive, and yet concise. Upon those subjects usua 
found difficult to the student, he has dwelt at len; 
and entered into full explanation. After a care 
perusal of its contents, we can unhesitatingly com- I 



"OYNBEE {JOSEPH), F. R. S., 

Aural Surgeon to and Lecturer on Surgery at St. Mary's Hospital. 

THE DISEASES OF THE EAR: their Nature*, Diagnosis, and Treat- 

ment. With one hundred engravings on wood. Second American edition. In one very 
handsomely printed octavo volume of 440 pages ; extra cloth, $4. 



T A URENCE [JOHN Z.), F. R. C. S., 

"^ Editor of the Ophthalmic Review, &c. 

A HANDY-BOOK OF OPHTHALMIC SURGERY, for the use of 

Practitioners. Second Edition, revised and enlarged. With numerous illustrations. In 
one very handsome octavo volume, extra cloth, $3 00. {Lately Issued.) 
This is, as its name suggests, a book for convenient | the subject, or those recently published by Stellwag, 
reference rather than an exhaustive treatise, and as Wells, Bader, and others, Mr. Laurence will prove a 
such it will be found very valuable to the general safe and trustworthy guide. He has described in this 
physician. It gives in very brief terms the symp- edition those novelties which have secured the confl- 
toms and history of the various diseases of the eye, dence of the profession since the appearance of hi 



'ith just enough cases detailed to elucidate the text 
without confusing the reader. His chapter on exami- 
nation of the eye is particularly good, and, it seems 
to us, better calculated to enlighten a novice than 
any similar instructions we have read. — California 
Med. Gazette, Jan. 1S70. 

For those, however, who must assume the care of 



last. To the portion of the book devoted to a descrip- 
tion of the optical defects of the eye, the publisher 
has given increased value by the addition of several 
pages of Snellen's test-types, so generally used to test 
the acuteness of vision, and which are difficult to ob- 
tain in this country. The volume has been conside- 
rably enlarged and* improved by the revision and ad- 
diseases and injuries'of the eye, and who "are "too ! ditions of its author, expressly for the American 
much pressed for time to study the classic works on j edition —Am. Journ. Med Sciences, Jan. 1870. 

A WSON (GEORGE), F. R. O. S, Engl, 

Assistant Surgeon to the Royal London Ophthalmic Hospital, Moorfields, &c. 

INJURIES OF THE EYE, ORBIT, AND EYELIDS : their Imme- 

diate and Remote Effects. With about one hundred illustrations. In one very hand- 
some octavo volume, extra cloth, $3 50 

It is an admirable practical book in the highest and best sense of the phrase. — London Medical Times 
and Gazette, May IS, 1S67. 



L 



M 



ORLAND (TV. W.), M.D. 

DISEASES OF THE URINARY ORGANS; a Compendium of their 

Diagnosis, Pathology, and Treatment. With illustrations In one large and handsome 
octavo volume of about 600 pages, extra cloth. $3 50. 



~DRYANT {THOMAS), FR.C.S. 

THE PRACTICE OF SURGERY. A Manual, with numerous 

engravings on wood. In one very handsome volume. {Preparing-.) 



30 



Henry C. Lea's Publications — (Surgery, &c). 



TUALES {PHILIP S.), M. D., Surgeon U. 8. N. 



MECHANICAL THERAPEUTICS: a Practical Treatise on Surgical 

Apparatus, Appliances, and Elementary Operations : embracing Minor Surgery, Band- 
aging, Orthopraxy, and the Treatment of Fractures and Dislocations. With six hundred 
and forty-two illustrations on wood. In one large and handsome octavo volume of about 
700 pages: extra cloth, $5 76; leather, $6 75. 
A Naval Medical Board directed to examine and report upon the merits of this volume, officially 
states that " it should in our opinion become a standard work in the hands of every naval sur- 
geon ;" and its adoption for use in both the Army and Navy of the United States is sufficient 
guarantee of its adaptation to the needs of every-day practice. 

It is a unique specimen of literature in its way, in 
that, ti-eating upon such a variety of subjects, it is as a 
whole so completely up to the wants of the student 
and the general practitioner. We have jnever seen 
any work of its kind that can compete with it in real 
utility and extensive adaptability. In conclusion, 
we would state, at the risk of reiteration, that this 
is the most comprehensive book on the subject that we 
have seen ; is the best that ca n be placed in the hands 
of the student in need of a first book on surgery, and 
the most useful that can be named for such general 
practitioners who, without any special pretensions 
to surgery, are occasionally liable to treat surgical 
cases.— N. Y. Med. Record, March 2, 1868. 

It is certainly the most complete and thorough work 
of its kind in the English language. Students and 
young practitioners of surgery willhnd it invaluable. 



It will prove especially useful to inexperienced coun- 
try practitioners, who are continually required to 
take charge of surgical cases, under circumstances 
precluding them from the aid of experienced surgeons. 
—Pacific Med. and Surg. Journal, Feb. 1868. 

The title of the above work is sufficiently indica- 
tive of its contents. We have not seen for a long 
time (in the English language) a treatise equal to this 
in extent, nor one which is better adapted to the 
wants of the general student and practitioner. It is 
not to the surgeon alone that this book belongs ; the 
physician has frequent opportunities to fill an emer- 
gency by such knowledge as is here given. Every 
practitioner should make purchase of such a book — 
it will last him his lifetime. St. Louis Med. Re- 
porter, Feb. 1868. 



/THOMPSON {SIR HENRY), 

-*■ Surgeon and Professor of Clinical Surgery to University College Hospital. 

LECTURES ON DISEASES OF THE URINARY ORGANS. 

illustrations on wood. In one neat octavo volume, extra cloth. $2 25. 



These lectures stand the severe test. They are in- 
structive without being tedious, and simple without 
being diffuse; and they include many of those prac- 
tical hints so useful for the student, and even more 
valuable to the yonng practitioner. — Edinburgh Med. 
Journal, April, 1869. 

Very few words of ours are necessary to recommend 
these lectures to the profession. There is no subject 



on which Sir Henry Thompson speaks with 
thority than that in which he has specially 
his laurels; in addition to this, the conve 
style of instruction, which is retained in thes 
lectures, gives them an attractiveness whic 
tematic treatise can never possess. — London 
Times and Gazette, April 21, 186.9. 



With 



more au- 
gathered 
rsational 
e printed 
h a sys- 
Medic.al 



T>Y THE SAME AUTHOR. 

ON THE PATHOLOGY AND TREATMENT OF STRICTURE OF 

THE URETHKA AND URINARY FISTULA. With plates and wood-cuts. From the 
third and revised English edition. In one very handsome octavo volume, extra cloth, %'6 50. 
(Just Isstied.) 
This classical work has so long been recognized as a standard authority on its perplexing sub- 
jects that it should be rendered accessible to the American profession. Having enjoyed the 
advantage of a revision at the hands of the author within a few months, it will be found to present 
his latest views and to be on a level with the most recent advances of surgical science. 

With a work accepted as the authority upon the 1 ably known by the profession as this before us, must 
subjects of which it treats, an extended notice would | create a demand for it from those who would keep 
be a work of supererogation. The simple announce- I themselves well up in this department of surgery. — 
rnent of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. 



/TAYLOR {ALFRED S.), M.D., 

-*■ Lecturer on Med. Jurisp. and Chemistry in Guy's Hospital. 

MEDICAL JURISPRUDENCE. Sixth American, from the eighth 

and revised London edition. With Notes and References to American Decisions, by Cle- 
ment B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, 
extra cloth, $4 50 ; leather, $5 oQ. 



The sixth edition of this popular work comes to us 
in charge of a new editor, Mr Penrose, of the Phila- 
delphia bar, who has done much to render it useful, 
not only to the medical practitioners of this country, 
but to those of his own profession. Wisely retaining 
the references of the former American editor, Dr. 
Hartshorne, he has added many valuable notes of his 
own. The reputation ot Dr. Taylor's work is so well 
established, that it needs no recommendation. He is 
now the highest living authority on all matters con- 
nected with forensic medicine, and every successive 
edition of his valuable work gives fresh assurance to 
his many admirers that he will continue to maintain 
his well-earned position. No one should, in fact, be 
without a text-book on the subject, as he does not 



know but that his next case Jjnay create for him an 
emergency for its use. To those who are not the foi> 
tuuate possessors of a reliable, readable, interesting, 
and thoroughly practical work upon the subject, we 
would earnestly recommend this, as forming the best 
groundwork for all their future studies of the more 
elaborate treatises. — New Fork Medical Record, Feb. 
15, 1S<J7. 

The present edition of this valuable manual is a 
great improvement on those which have preceded it. 
it makes thus by far the best guide-book in ihis de- 
partment of medicine for students and the general 
practitioner in our language. — Boston Med. and Surg . 
Journal, Dec. 27, 1866. 



Henry C. Lea's Publications — {Medical Jurisprudence, &c). 31 



-DLANDFORD {G. FIELDING), M. D., F. R. C P., 

•*-* Lecturer on Psychological Medicine at the School of St. George's Hospital, &c. 

INSANITY AND ITS TREATMENT: Lectures on the Treatment, 

Medical and Legal, of Insane Patients. With a Summary of the Laws in force in the 
United States on the Confinement of the Insane. By Isaac Ray, M. D. In one very 
handsome octavo volume of 471 pages: extra cloth, $3 25. {Just Issued.) 
This volume is presented to meet the want, so frequently expressed, of a comprehensive trea- 
tise, in moderate compass, on the pathology, diagnosis, and treatment of insanity. To render it of 
more value to the practitioner in this country, Dr. Ray has added an appendix which affords in- 
formation, not elsewhere to be found in so accessible a form, to physicians who may at any moment 
be called upon to take action in relation to patients. 

It satisfies a want which must have been sorely 
felt by the busy general practitioners of this country. 
It takes the form of a manual of clinical description 



of the various forms of insanity, with a description 
of the mode of examining persons suspected of in- 
sanity. We call particular attention to this feature 
of the book, as giving it a unique value to the gene- 
ral practitioner. If we pass from theoretical conside- 
rations to descriptions of the varieties of insanity as 
actually seen in practice and the appropriate treat- 
ment for them, we find in Dr. Blandford's work a 
considerable advance over previous writings on the 
subject. His pictures of the various forms of mental 
disease are so clear and good that no reader can fail 
to be struck with their superiority to those given in 
ordinary manuals in the English language or (so far 



as our own reading extends) in any other. — London 
Practitioner, Feb. 1871. 



Dr. Blandford's book well meets the prevailing de- 
ficiency, and is one of that class, unhappily too small, 
which prove a real blessing to the busy practitioner 
who has no other time for reading but those odd mo- 
ments which he can catch in his brief intervals of 
leisure. It is so free from defects and is so fair a re- 
presentation of the most approved views respecting 
insanity, that we find in it small occasion for criti- 
cism, and can do little more than commend it as an 
admirable manual for practical use. We end as we 
began, in heartily recommending it as a most useful 
and reliable guide to the general practitioner. — Am. 
Journal Med. Sciences, April, 1S71. 



VyiNSLOW {FORBES), M.D., D.C.L., frc. 

ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS 

OF THE MIND j their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- 
phylaxis. Second American, from the third and revised English edition. In one handsome 
octavo volume of nearly 600 pages, extra cloth. $4 25. {Lately Issued.) 
A work which, like the present, will largely aid 

the practitioner in recognizing and. arresting the first 

insidious advances of cerebral and mental disease, is 

one of immense practical value, and demands earnest 

attention and diligent study on the part of all who 

have embraced the medical profession, and have 



thereby undertaken responsibilities in which the 
welfare and happiness of individuals and families 
are largely involved. We shall therefore close this 



brief and necessarily very imperfect notice of Dr. 
Winslow's great and classical work by expressing 
our conviction that it is long since so important and 
beautifully written a volume has issued from the 
British medical press. — Dublin Medical Press. 



It is the most interesting as well as valuable book 
that we have seen for a long time. It is truly fasci- 
nating. — Am. Jour. Med. Sciences. 



T EA {HENRY C). 

SUPERSTITION AND FORCE: 

LAW, THE WAGER OF BATTLE, THE 
Enlarged. In one handsome volume roya 
{Just Issued.) 

We know of no single work which contains, in so | 
small a compass, so much illustrative of the strangest 
operations of the human mind. Foot-notes give the 
authority for each statement, showing vast research 
and wonderful industry. We advise our confreres 
to read this bo&kand ponder its teachings. — Chicago 
Med. Journal, Aug. 1870. 

As a work of curious inquiry on certain outlying 
points of obsolete law, "Superstition and Force" is 
one of the most remarkable books we have met with. 
— London AthencEum, Nov. 3, 1S6'6. 

He has thrown a great deal of light upon what must 
be regarded as one of the most instructive as well as 



ESSAYS ON THE WAGER OF 

ORDEAL, AND TORTURE. Second Edition, 
I 12mo. of nearly 500 pages; extra cloth, $2 75. 

interesting phases of human society and progress. 
The fulness and breadth with which he has carried 
out his comparative survey of this repulsive field of 
history [Torture], are such as to preclude our doing 
justice to the work within our present limits. But 
here, as throughout the volume, there will be found 
a wealth of illustration and a critical grasp of the 
philosophical import of facts which wili render Mr. 
Lea's labors of sterling value to the historical stu- 
dent. — London Saturday Review, Oct. S, 1S70. 

As a book of ready reference on the subject, it is of 
the highest value. — Westminster Review, Oct. lSt>7. 



73 F THE SAME AUTHOR. {Just Issued.) 

STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- 
PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 
12mo. volume of 516 pp. extra cloth. $2 75. 

The story was never told more calmly or with , literary phenomenon that the head of one of the first 
greater learning or wiser thought. We doubt, indeed, , American houses is also the writer of some of its most 
if any other study of this field can be compared with ! original books.— London Athenceum, Jan 7, 1871 
this for clearness accuracy, and power.- Chicago i Mr> Lea has doQe t h<mor tQ Mmself amJ ' 

Examiner, Dec. 18/0. country by the admirable works he has written on 

Mr. Lea's latest work, "Studies in Church History," I ecclesiologicaland cognate subjects. We have already 
fully sustains the promise of the first. It deals with j had occasion to commend his "Superstition and 
three subjects— the Temporal Power, Benefit of Force" and his "History of Sacerdotal Celibacy." 
Clergy, and Excommunication, the record of which The present volume is fully as admirable iu its me- 
has a peculiar importance for the English student, and i thod of dealing with topics and in the thoroughness — 
is a chapter on Ancient Law likely to be regarded as j a quality so frequently lacking in American authors- 
final. We caD hardly pass from our mention of such I with which they are investigated. — N. Y. Journal of 
works as these— with which that on "Sacerdotal I Psychol. Medieine, July, 1870. \ 
Celibacy" should be included — without noting the j 



32 



Henry C. Lea's Publications. 



INDEX TO CATALOGUE 



American Journal of the Medical Sciences 
Abstract, Half-Yearly, of the Med Sciences 
Anatomical Atlas, by Smith and Horner 
Ashton on the Kectum and Anus . 
Attfield's Chemistry .... 
Ash/well on Diseases of Females . 
Ashhurst's Surgery .... 

Barnes on Diseases of Women 
Bryant's Practical Surgery . 
Blandford on Insanity .... 
Basham on Renal Diseases . 
Brinton on the Stomach 
Bigelow on the Hip .... 

Barclay s Medical Diagnosis . 
Barlow's Practice of Medicine 
Bowman's (John E.) Practical Chemistry 
Bowman's (John E.) Medical Chemistry 
Brande & Taylor's Chemistry 
Buckler on Bronchitis .... 
Bncknill and Tuke on Insanity . 
Bumstead on Venereal .... 
Bumstead and Cullerier's Atlas of Venereal 
Carpenter's Human Physiology . 
Carpenter's Comparative Physiology . 
Carpenter on the Use and Abuse of Alcohol 
Carson's Synopsis of Materia Medica . 
Chambers on the Indigestions 
Chambers's Restorative Medicine 
Christison and Griffith's Dispensatory 
Churchill's System of Midwifery . 
Churchill on Puerperal Fever 
Condie on Diseases of Children . 
Cooper's (B. B.) Lectures on Surgery . 
Cullerier's Atlas of Venereal Diseases 
Cyclopedia of Practical Medicine . 
Dalton's Human Physiology . 
De Jongh on Cod-Liver Oil . 
Dewees's System of Midwifery 
Eewees on Diseases of Females . 
Dewees on Diseases of Children . 
Druitt's Modern Surgery 
Dunglison's Medical Dictionary . 
Dunglison's Human Physiology . 
Dunglison on New Remedies 
Ellis's Medical Formulary, by Smith . 
Erichsen's System of Surgery 
Erichsen on Nervous Injuries 
Flint on Respiratory Organs . 

Flint on the Heart 

Flint's Practice of Medicine . 
Fownes's Elementary Chemistry . 
Fulleron the Lungs, &c. 
Green's Pathology and Morbid Anatomy 
Gibson's Surgery . . • • T • 
G luge's Pathological Histology, by Leidy 
Graham's Elements of Chemistry . 

Gray's Anatomy 

Griffith's (R. E.) Universal Formulary 
Gross on Foreign Bodies in Air-Passages 
Gross's Principles and Practice of Surgery 
Gross's Pathological Anatomy 
Guersant on Surgical Diseases of Children 
Bartshorne's Essentials of Medicine . 
Rartshome's Conspectus of the Medical Scien< 
Hamilton on Dislocations and Fractures 
Heath's Practical Anatomy . 
Hoblyn's Medical Dictionary 

Hodge on Women 

Hodge's Obstetrics 

Hodges' Practical Dissections 
Holland's Medical Notes and Reflections 
Horner's Anatomy and Histology 
Hudson on Fevers, .... 

Hill on Venereal Diseases . 
Hillier's Handbook of Skin Diseases 
Jones and Sieveking's Pathological Anatomy 
Jones (C. Handheld) on Nervous Disorders 
Kirkes' Physiology . , 
Knapp's Chemical Technology 



PAGE 
1 

3 
6 

28 
10 
22 
27 
22 
29 
31 
IS 
15 
2S 
14 
15 
10 
10 
11 
17 
14 
19 
19 



by Leidy 



Lea's Superstition and Force 
Lea's Studies in Church History . 
Lallemand and Wilson on Spermatorrhoea 
La Roche on Yellow Fever . 
La Roche on Pneumonia, &c. 
Laurence and Moon's Ophthalmic Surgery 
Lawson on the Eye .... 

Laycock on Medical Observation . 
Lehmann's Physiological Chemistry, 2 vols, 
Lehmann's Chemical Physiology . 
Ludlow's Manual of Examinations 

Lyons on Fever 

Maclise's Surgical Anatomy . 

Marshall's Physiology .... 

Medical News and Library . 

Meigs's Obstetrics, the Science and the Art 

Meigs's Lectures on Diseases of Women 

Meigs on Puerperal Fever 

Miller's Practice of Surgery . 

Miller's Principles of Surgery 

Montgomery on Pregnancy . 

Morland on Urinary Organs . 

Morland on Uraemia .... 

Neill and Smith's Compendium of Med. Sc: 

Neligan's Atlas of Diseases of the Skin 

Neligan on Diseases of the Skin . 

Odling's Practical Chemistry 

Pavy on Digestion .... 

Prize Essays on Consumption 

Parrish's Practical Pharmacy 

Pirrie's System of Surgery . . . 

Pereira's Mat. Medica and Therapeutics, abr 

Quain and Sharpey's Anatomy 

Ranking's Abstract 

Radcliff and others on the Ner 

Roberts on Urinary Diseases . 

Ramsbotham on Parturition . 

Rigby's Midwifery 

Rokitansky's Pathological Anatomy . 

Royle's Materia Medica and Therapeutics 

Salter on Asthma ..... 

Swayne's Obstetric Aphorisms 

Sargent's Minor Surgery 

Sharpey and Quain's Anatomy, by Leidy 

Simon's General Pathology . 

Skey's Operative Surgery 

Slade on Diphtheria .... 

Smith (J. L.) on Children 

Smith (H. H.) and Horner's Anatomical Atl 

Smith (Edward) on Consumption . 

Smith on Wasting Diseases of Children 

Solly on Anatomy and Diseases of the Brain 

Still^'s Therapeutics 

Tanner's Manual of Clinical Medicine 

Tanner on Pregnancy 

Taylor's Medical Jurisprudence . 

Thomas on Diseases of Females . 

Thompson on Urinary Organs 

Thomp-on on Stricture . 

Todd and Bowman's Physiological Anatomy 

Todd on Acute Diseases .... 

Toynbee on the Ear .... 

Wales on Surgical Operations 

Walshe on the Heart .... 

Watson's Practice of Physic . 

Wells on the Eye . . . . t . 

West on Diseases of Females 

West on Diseases of Children 

West on Nervous Disorders of Children 

West on Ulceration of Os Uteri 

What to Observe in Medical Cases 

Williams's Principles of Medicine 

Williams on Consumption . 

Wilson's Human Anatomy ... 

Wilson on Diseases of the Skin 

Wilson's Plates on Diseases of the Skin 

Wilson's Handbook of Cutaneous Medicin 

Wilson on Spermatorrhoea 

Winslow on Brain and Mind 



PA OB 
31 



dged 



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ndi 



■ 



■ 



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